Mansell, Engel & Cole

Why did your health insurance deny your claim?

Like many in Oklahoma, you may have insurance on your own dime and not through your employer. Since this is often expensive, it can be frustrating to have the insurer deny a claim you feel is legitimate. Often these issues arise when a policyholder is not familiar with the terms of the policy, but they can also come about through intentionally deceptive, or "bad faith," actions on the insurer's part.

It can be a mistake to assume that your health insurance policy will cover everything health-related. In fact, there are many situations that your policy may exclude, and you may find those exclusions listed on your policy documents. However, it is not always clear what the insurer will decide about a claim.

What is hidden in your policy language?

The worst time to learn that your health insurance policy will not cover some medical situation is when you are in the middle of that situation and have already incurred expenses. Since every state has different laws about what an insurer can and cannot exclude from a policy, you would be wise to seek legal counsel if you are unclear about your policy's terms. However, in general, many health insurance providers will not cover a claim under the following circumstances:

  • Your illness or injury resulted from an unlawful act, such as those suffered while under the influence of illegal drugs.
  • Your doctor admits you to the hospital under observation instead of as an inpatient, even if you stay overnight for observation.
  • Your doctor admits you under inpatient status for treatment the insurer feels could have been handled as well under outpatient services.
  • You enter a nursing home for custodial care, such as help with daily activities, rather than for medical care or rehabilitation.
  • You enter a nursing home, move to assisted living or obtain in-home health services for long-term care.
  • You obtain vaccinations against tropical diseases because you are planning a trip to another country.
  • You receive an MRI, CT scan or other expensive procedure, even after receiving pre-authorization, and the insurer later decides it was medically unnecessary.

As you can see, many of the reasons why your health insurance provider may deny your claim hinge solely on the insurer's judgment about the necessity or value of your treatment. This is why it is not wise to simply accept a claim denial without reaching out for legal advice. An attorney with experience dealing with insurance company tactics and bad faith actions will fight for the benefits you deserve.

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