Health insurance is one of the most complicated, tedious areas of insurance to understand and navigate.  Moreover, a health insurance claim denial can threaten your financial security and effect your ability to access medical care. The first thing to do is to identify the insurer’s reason for denying your claim. The insurer, your doctor, or the hospital may be able to help explain the insurer’s stated reasons for refusing coverage. The reasoning behind a denial will provide some insight as to your options.

COMMON HEALTH INSURANCE CLAIM DENIALS

  • DENIAL OF SERVICES OR PROCEDURES NOT COVERED BY YOUR POLICY
  • DENIAL BECAUSE A PROCEDURE IS CONSIDERED EXPERIMENTAL, COSMETIC, INVESTIGATIONAL, OR NOT MEDICALLY NECESSARY
  • DENIAL BECAUSE A REFERRAL OR PRE-AUTHORIZATION WAS REQUIRED
  • DENIAL BECAUSE YOU USED AN OUT-OF-NETWORK PROVIDER
  • DENIAL FOR TYPOGRAPHICAL ERRORS
  • DENIAL FOR TIMELINESS
  • DENIAL DUE TO POLICY LIMITATIONS

Many of these reasons for denial can be addressed, either by appealing the insurer’s decision, or by contacting the doctor or hospital to make corrections to the documents submitted. When an insurer refuses to pay a claim, you may respond or appeal in the form of a letter that includes your best arguments against the decision and any supporting evidence or documentation. This appeal should focus on the specific grounds for denial that were listed in the notice of denial provided to you by the insurer. Where an appeal is unsuccessful and the insurer refuses to accept your valid claim you may need to sue them for their claim denial.


DO YOU HAVE QUESTIONS RELATED TO A HEALTH INSURANCE DISPUTE?

If you or a loved one have been affected by a health insurance dispute, we encourage you to consult with our team as soon as possible. With our extensive knowledge and expertise, you can rest assured that should you choose to work with us, you will have legal representation that you can trust. At Fulmer Sill, all initial consultations are free, and we don’t charge any up-front fees for representation. We handle all fees on a contingency basis, meaning that unless we’re successful, you don’t have to pay us. Please contact Fulmer Sill at (405)510.0077 for a free consultation.