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Why do insurers deny medical claims?

On Behalf of | Jun 12, 2023 | Denied Insurance Claims

If you receive medical treatment in Oklahoma City, you may file a claim with your health insurance company to cover your medical expenses. While the insurance company may act like it wants to make sure you are able to get the treatment you need, it is doing everything it can to avoid paying you benefits.

Here are some of the most common reasons health insurance companies deny claims.

Lack of medical necessity

Insurance companies will generally only cover treatments and procedures deemed as medically necessary. You may think that if your doctor decides that it is in your best interest to administer treatment, that automatically makes your treatment necessary. However, the insurance company may not see it that way.

For example, the insurer may claim that there was a cheaper treatment available and refuse to cover the treatment you received, even if the cheaper treatment would have been less effective.

Claim filing errors

If the claim is not filed by the requisite deadline, includes misinformation, or lacks necessary information, the insurance company will be quick to deny your claim.

Experimental treatment

The insurance company may attempt to avoid high costs by avoiding covering experimental, high-risk treatments with unproven results.

If your claim has been denied by an insurance company for any reason, you may be able to appeal the decision. You may file an internal appeal to ask your insurer to reconsider your claim based on additional information from your health care provider. If your insurer still denies your claim, you may request a third party to perform an external review of your case.