Mansell, Engel & Cole

With health insurance, a delay may be as bad as a denial

Health care and how to pay for it is top of mind for nearly everyone in Oklahoma and the rest of the country right now. The political realities of the issue make it so. But if you or a loved one is on the receiving end of a diagnosis for some major illness that requires significant, long-running treatment, the issue takes on a sense of urgency.

Insurance coverage is in place for many more people than used to be the case because of federal laws. However, that doesn't necessarily mean that the access gates to care have been thrown open. If a legitimate claim comes back underpaid, if payment is delayed, or the claim is denied, battling for benefits you are due becomes a priority – just when you need to be focused on conquering your condition.

If your insurance company denies your claim for coverage, that's not the end of the story. You have rights and may well have options for holding the company accountable. The effort can be stressful and time consuming, and where health care is concerned, delays only add to the strain.

Insurers give many reasons for why they are underpaying, delaying payment or denying coverage altogether. In the first instance, they might say the charge is higher than what is usual and customary – a rather subjective point of view. A company might say the claim lacked details, stalling payment. If recommended treatment is relatively new, the insurer might call it experimental and deny the claim.

Actions can be appealed, but they have to be in writing. The effort needs to clearly articulate your best argument against the denial and might need to include additional medical evidence. Knowing what will be required and how to best present it requires skill and an understanding of legal contracts. Consulting an attorney is always recommended.

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