Mansell, Engel & Cole

What should I know about appealing a denied claim? Pt. 1

As many debates as there are regarding health care in the U.S. right now, just about everyone can agree on one health insurance matter. When your insurance company denies to cover a claim that you know should be covered, it can feel like a punch in the gut. 

A claim denial tends to create a mix of feelings: confusion, worry, frustration and anger. Those who do not work with or for health insurance providers can easily feel overwhelmed and too daunted to fight for what they deserve. Some who receive notice of claim denials won't even ask questions. They might assume they were mistaken and that their provider knows best. Don't be one of those people.

A denial of coverage for a health insurance bill does not necessarily represent what is accurate. Insurance companies can get it wrong; they might even act in bad faith and try to get away with mistreating you and others who are owed coverage. There is an appeals process in place in order to try to get the coverage to which you are entitled and to hold insurance providers accountable. 

What are some of the basic aspects of the appeals process? First, you or someone in the position of facing a denied claim might wonder if your claim is eligible for appeal. Healthcare.gov notes that there are various reasons why a provider might refuse to pay a claim. The following are some of the reasons you might have to fight:

  • Your plan states that the specific treatment you received isn't covered.
  • Your plan doesn't cover pre-existing matters and deems the treatment it is not covering as such.
  • Your provider argues that your treatment was not medically necessary.
  • Your provider claims that you used false information when enrolling for coverage, making you ineligible to be covered by the plan entirely. 

Are you faced with any of the above arguments and willing to refute a company's reason for denying your coverage? If so, turn to an experienced insurance lawyer who knows how to properly and effectively represent your rights. 

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