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What if the health insurance company deems treatment unnecessary?

On Behalf of | Feb 4, 2021 | Denied Insurance Claims

Health insurance is a fundamental need for Oklahomans. Since medical treatment can be so exorbitantly expensive, it is a comfort to know that their expenses will be paid when they visit a doctor or hospital, have procedures performed, receive treatment and other types of healthcare. It can be worrisome and outright frightening if a health insurance company assesses a claim and decides not to pay it by saying the treatment was not medically necessary. The insurer does have the right to deny a claim, but it must be done for a legitimate reason. Understanding the law for denial of payment is imperative when there is a dispute, as is having legal assistance.

Medical necessity and an insurance claim denial

Except in cases where the insurance company was informed by the medical provider that the procedure or treatment was medically unnecessary, the denial constitutes an unfair settlement claim practice. A medical examination or claim review must be conducted to show that the care was not needed. A reviewing physician will conduct the assessment of the claim.

Claimants, physicians or hospitals then have the right to request a written report by the physician who reviewed the record and deemed the treatment unnecessary. There must be detail as to why this is the case and an explanation why there was this conclusion. Copies of the report must be sent to the relevant parties within 15 days of the written request being made.

Having legal help can be crucial when denied payment for medical care

It is unfortunate that companies that are purportedly in existence to give policyholders peace of mind when they need medical care will try to use various tactics to mitigate their costs and deny claims. Insurers do not have the right to mistreat customers in this way without a viable and legal reason to do so. There can be compensation and punitive damages if they are found to have taken part in this behavior. People who dealt with the litany of challenges that accompany a denied health insurance claim should consult with legal professionals experienced in holding these companies accountable.