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Health Insurance Denial

Health Insurance Denial

When you get a new job, one of the first questions your friends and family will ask you is, “How are the benefits?” Health insurance has become a component that most Americans cannot live without. A major goal for us, when it comes to our careers, is to secure a job that provides a great health insurance policy to cover the needs of not only ourselves, but also our families. But, what happens when we finally get the insurance policy we want, but the insurer fails to follow through on their end? Obtaining the policy itself is not your last stop, though some people may assume it is. The truth is that once you sign that policy agreement, the battle of making sure the insurance company upholds their end of the deal begins, and it can be a continuous, uphill battle with each claim you file. 

Why Would My Insurance Company Deny My Claim?

There are several reasons why you may have been denied coverage. As you will see below, not all reasons fall on you personally. Sometimes, your coverage is denied due to a clerical error or an accidental oversight of documents. 

Here are a few ways you may be denied coverage:

  • You failed to respond to a notice in the mail regarding your insurance plan. These notices are not junk mail, but many people assume they are. These notices often include strict requirements to ensure your continued coverage. If left unchecked, you could compromise the validity of your policy.
  • You received medical treatment that was out of your network. You should always double check to make sure the appointment you made is at a clinic or hospital that is within your network. This is often an easy question that can be answered when you call to make the appointment. 
  • Your medical treatment was considered experimental by the insurance company. Just because you feel treatment was necessary for your health does not mean the insurer agrees. Unless you are referred for the treatment because it is deemed the only option, there is a good chance your insurance will mark this appointment as an experimental option that was neither necessary nor crucial. 
  • Someone coded your appointment incorrectly. This is a simple mistake that can be easily fixed if it is caught quickly. Clerical errors are another reason why it is so important to pay attention to updates to your policies and bills received in the mail.
  • A hired third party decided to deny your claim. Some insurance companies hire another company to deal with the process of approving or denying claims, and these third party companies often do so with their own specific set of regulations and rules. 

The important part here is that you learn to read your policy carefully. Reading the details of your plan in the beginning is not sufficient for your continued understanding of the policy because it is likely to change every year. When you get notices in the mail or through your email, make yourself stop and truly read through each message so that you have the most up-to-date information for you and your family. If a health management organization can pull one over you by glossing over important information, it will. Never forget that these organizations are businesses first, and their main goal is to make money off of your policy. Saving you money is not their focus. Do not make it any easier for them by neglecting your responsibility to read your policy and bills carefully. If you have any questions or concerns about reading your policy statements, reach out to a trusted lawyer who can easily translate the terms and agreements for you. 

What Do I Do After My Claim Has Been Denied?

Insurance claim denials never have to be the final answer, so take comfort in knowing you still have options to fix whatever issue is at hand. Usually, when a claim is denied, you will receive an Explanation of Benefits (EOB) in the mail or through your email. This document can look like boring information about your insurance policy, but do not ignore it. Again, get into the habit of reading anything you receive in the mail that comes from your insurance company. Once you receive that EOB document, contact your insurance company directly to see if it is one of the easier fixes mentioned in the list above. If so, you may be able to remedy this denial in a matter of minutes by sending in any necessary documents. If the denial is something you cannot quickly fix, then you have two options:

File an Internal Appeal

With this option, you ask your insurance provider to do a thorough investigation into your claim and its denial. The motive is that you give the company itself the chance to catch any mistakes that may have happened on their end before you take the issue to someone else. 

File an External Appeal

If the insurance company completes the investigation from your internal appeal and they still uphold the denial, then you have the right to move on to an external appeal. In this situation, you would hire an attorney to represent you in court as you continue to fight the insurance claim denial. 

Contact Us Today

Dealing with insurance claims and denials can be a headache for anyone. To make sure you are not wasting your time or efforts, contact us today at Keller, Melchiorre & Walsh. Our experience in health insurance denials is to your benefit, and we are ready to share our expertise with you. With several cases of this nature under our belt, we already anticipate the forms that need to be completed and the steps that need to be taken. You should be able to focus on the medical attention you need without the distractions of legal confusion and insurance companies. Give us a call today so that we can help you create a plan that will save you both time and money in the long run.

Contact Us Today!

The attorneys and staff at Keller, Melchiorre & Walsh PLLC are here to help you. If you have been injured or harmed as a result of the actions of others or if you are facing criminal prosecution, don’t wait. Call us now for a free strategy session.

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