Insurance companies may deny claims for many reasons. If your insurance claim has been denied, it is important that you understand why your insurance company denied your claim as well as any steps you can take to appeal your insurance company’s denial.
Why Would an Insurance Claim Be Denied?
Understanding why your insurance company denied your claim is the first step to resolving the issue. Reasons for insurance claim denials may be a result of the following:
- Your insurance policy may not cover certain procedures or services.
- A particular procedure or service may be not be considered medically necessary, even if you think it was.
- You failed to provide a doctor’s referral or pre-authorization. (In most cases, your doctor will make the request on your behalf, but you may need to ask them.)
- You used an out-of-network provider.
- Your claim was submitted with typographical mistakes or data entry errors.
- Your claim was not submitted on time.
If your claim has been denied, take a look at the claim you submitted along with the insurance policy itself. It is important that you read and understand your health insurance policy as best you can. Health insurance companies that offer group or individual coverage must provide a Summary of Benefits and Coverage under federal law. Your rights and responsibilities as an insured party are most likely covered in detail in your policy.
Before beginning the appeals process, give your insurance company a phone call. If your claim has been denied due to a typo or data entry error, you can potentially alleviate the situation while you are on the phone.
If your denial is more complex, or if your insurance company refuses to pay your claim, you will need to begin the appeals process. Regardless of the complexity or difficulty of your claim, take detailed notes during any phone conversation with insurance company representatives. Be sure to get the representative’s name and extension as well as the date and time when the correspondence took place.
Appealing Your Insurance Company’s Decision
If your insurance company continues to deny your claim, you have the right to pursue a more formal appeals process with the company. When your insurance claim has been denied, you should receive a letter explaining why. In most cases, the letter will explain how you can appeal the denial and within what amount of time.
In order to begin the process, be sure you understand why your claim has been denied and how much time you have to appeal the denial. It is critical that you begin gathering any and all documents associated with the claim as well, including any notes you may have.
Once you have your information, you will need to submit a letter to your insurance company requesting that your claim be reconsidered. The letter you submit should be as detailed as possible. Be sure to include any evidence in support of your claim, and keep a copy of everything you send to your insurance company.
Help with Your Insurance Claim
Just as you have the right to appeal your insurance company’s decision, you can have it reviewed by an independent, third-party organization. In some cases, those organizations and companies will handle your appeal at no cost. Likewise, you can also contact your state’s insurance department for help.
In most cases, insurance claims are denied based on “good faith” interpretation of the policy; however, some insurance companies might engage in “bad faith” or unfair claims handling practices. If you think your insurance company is intentionally deceiving or misleading its policyholders, committing fraud, or refusing to fulfill their contractual obligation, you may need to contact a lawyer who can help you better understand your rights and remedies.