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Why was my health insurance claim wrongfully denied?

On Behalf of | Apr 5, 2021 | Denied Insurance Claims

Many people know at least one person who is a cancer survivor or, sadly, lost their battle to cancer. However, when it comes to cancer, especially rare forms of cancer, the patient often needs extensive treatment and possibly in-home care. They may think that their health insurance will cover these costs. So, it can be very distressing if their insurer denies their claim, leaving them with a hefty medical bill that they may have no means of repaying.

Why might an insurer wrongly deny a claim?

There are a variety of reasons why an insurance company might wrongly deny payment for a health care service provided. They include:

  • Errors in papers: If there are errors in the paperwork submitted to the insurer, for example, if the doctor’s office spelled your name wrong or used the wrong billing code, your claim could be denied. Missing details could also lead to a denial.
  • Medical necessity. Sometimes an insurer will deny a claim, saying the service provided was not medically necessary. This unfortunately happens even if your doctor knows what treatment you needed and why. In this situation, your physician may have to provide your insurer with more information about why the service they provided was necessary.
  • Cost control. Insurers are ultimately looking out for their bottom line. They may try to deny a claim for an expensive service, saying there is a less expensive option available, even if this is not the case in your situation.
  • Coverage issues. Insurers may also deny a claim, stating that the service rendered is not covered under your policy. They may try to say a treatment is for cosmetic purposes only or is not approved by the U.S. Food and Drug Administration. Also, they may try to argue that the medical professional that provided services was out-of-network.

Learn more about denied medical insurance claims

Being denied a claim for any of these reasons is distressing, but there are steps you can take to appeal a denial. This post is for educational purposes only and does not contain legal advice. Our firm’s webpage on health insurance claim denials may be a good starting point for those who want to learn more about this topic.