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Why Would My Health Insurance Claim Be Denied?

When you have a health insurance policy, you expect that the insurance company will cover the medical expenses when you or your loved one is sick or injured. Unfortunately, insurance companies often use sneaky tactics in order to avoid paying out even legitimate health insurance claims.

The U.S. Department of Labor even estimates that one in seven health claims made under employee health plans are initially denied—equating to about 200 million claims per year. Knowing the duties of your insurance company, as well as the most common reasons why health insurance claims are denied, can help you ensure your rights are protected.

If your health insurance claim was denied, Aizenman Law Group can assist you in filing an appeal or a lawsuit in order to ensure you get your medical expenses covered. Contact our Tulsa insurance claim attorneys right away to discuss your case for free.

The Duties of a Health Insurance Company

The health insurance company has certain responsibilities and duties owed to you, the insured individual. If it can be proven by your insurance claim attorney that the insurance company failed to uphold these duties, it could mean that the insurance company acted in bad faith and they could face liability for damages. Some of the specific duties owed to you include:

  • Duty to Defend. If a third party brings a claim against their policyholder, the insurance company has a duty to defend this person.
  • Duty to Indemnify. This refers to the duty of the insurance company to pay for losses incurred by another party if you are found liable for them.
  • Duty to Act in Good Faith With Fair Dealing. The insurance company has a duty to protect the policyholder by acting in good faith.
  • Duty to Fairly and Quickly Manage Claims. This refers to the duty to promptly investigate all claims and provide the benefits of the policy in a timely manner.
  • Duty to Settle According to the Policy. The insurance company must settle a claim according to the specific policy and policy limits.
  • Duty to Disclose Conflicts. The insurance company must disclose any conflicts or issues that arise when it comes to paying out a claim.

Common Reasons for Health Insurance Claim Denials

When an insurance company refuses to pay a health care claim made by a policyholder, this is known as an insurance denial. Remember that insurance companies are businesses and their primary goal is to maximize profits. Even if you have a legitimate claim, the insurance company would rather find any reason to deny it than pay you out immediately.

Some of the most common reasons that insurance companies may use to deny health insurance claims include:

  • Medically Unnecessary. Even if you need the service, the insurance company may claim that the procedure or treatment was medically unnecessary.
  • Paperwork Error. Claim denial can often result from a mixup in paperwork or information; for instance, the name listed at your doctor’s office and for your insurance company could be different.
  • The Procedure Is Too Expensive. The insurance company may have wanted you to try a different, less expensive option for your medical procedure or treatment.
  • Not Covered By Your Plan. Insurance companies will oftentimes deny claims that call into broad categories by saying that the treatment is not covered.
  • Out-of-Network Medical Treatment. The medical treatment you received may not have been provided by an in-network healthcare provider.
  • Insufficient Detail. The administrating doctor may have not included sufficient detail as to why you needed the procedure/if it was medically necessary.
  • Untimely Claim. The insurance company may claim that you filed outside of the allotted time frame.
  • Rules Were Not Followed. The insurance company may claim that there were specific procedural rules that you did not follow; for instance, you needed pre-authorization from the insurance company before getting a specific test done.

Contact our Health Insurance Claim Attorneys

Without taking timely action after a denied health insurance claim, you could be slammed with thousands of dollars in medical bills. At Aizenman Law Group, our Tulsa insurance claim attorneys are no strangers to health insurance cases. With a sharp insight into why claims are denied and how to get them appealed, we understand what it takes to help our clients win.

Get the peace of mind that you need and deserve after a denied health insurance claim. Contact our firm at (918) 215-8856 to schedule your free, no-obligation consultation with our team today!