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Insurance companies are breaking the law in denying some claims

On Behalf of | May 28, 2024 | Insurance

When you secure health insurance, you expect that your insurer will step in during your time of need to help pay for your medical care. Yet, insurance companies often go out of their way to find justifications to deny claims. While this can take individuals by surprise, it has also left lawmakers who have implemented laws forcing insurance companies to pay for certain care shocked. A Pro Publica report from late last year shows just how devastating the problem can be for everyday people.

The types of claims being denied

The Pro Publica investigation found that various health insurance claims are being unlawfully denied, leaving patients on the hook for tens of thousands of dollars they shouldn’t have to pay. This includes:

  • Cancer medications required by state law to be covered by insurance companies.
  • Emergency medical services, including ambulance transportation, that were required to be covered by insurance.
  • Infertility treatments that are included under mandatory coverage provisions in state law.

There are likely countless other wrongful denials out there. The investigation found that one insurance company wrongfully overcharged a patient for birthing services on two occasions even after being notified that they had wrongfully denied her coverage after the first birth. It was subsequently found that the insurance company had improperly calculated coverage related to more than 1,000 births. Yet, the insurance company didn’t correct the problem and issue refunds until state regulators pushed them on the issue.

Health insurance remains confusing for most

Insurance coverage remains a mystery for most people. It’s hard to tell at a glance whether certain treatments and care will be covered, and you typically won’t know how much your medical care will cost until after you’ve already acquired it.

This issue is exacerbated by the fact that many employers are turning to federal-based policies that are exempt from state-mandated requirements. Therefore, even though the state has a law saying that insurance must cover a form of treatment, your policy may not extend that protection to you, and you may not even be aware of that limitation until it’s too late.

Most people don’t know what to do when they have a problem with their insurance coverage, either. The Pro Publica investigation found that only 86% of insured individuals know which governmental regulation agency to contact when they’re having an issue with their insurance company. As a result, many of these individuals end up simply swallowing the debt, which leaves them in a crushing financial position for years or decades, or perhaps even for the rest of their lives. Their only hope of getting out from under it is to educate themselves on the law and what they can do to find accountability and recover what they’re owed.

Has your insurance company denied you coverage?

If so, then be diligent in assessing the circumstances and how the law applies to the facts at hand. While you can try to resolve the issue with your insurance company on an informal basis, there’s a good chance that you’ll have to file an appeal or even an insurance lawsuit to get them to move from their position.

While that can sound scary and overwhelming, especially when you’re trying to focus on your medical condition, don’t be intimidated by the process. Instead, gather as much information as you can so that you can aggressively advocate for the outcome you deserve.