Content Overview
- Summary
- A Claim Denied On The Basis That The Procedure Or Treatment Is Not Medically Necessary
- A Claim Denied On The Basis That The Charges Are Not Usual, Customary and Reasonable ("UCR")
- A Claim Denied On The Basis That The Procedure Is Experimental
- A Claim Denied On The Basis That The Procedure Is Not A Covered Procedure
- A Claim Denied Due To Misrepresentation In The Application
- A Claim Denied On The Basis That The Specialist Or Facility Is Out Of Network
- A Claim Denied On The Basis That The Treatment Or Drug Is Not Likely To Cause Your Health Condition To Improve
- A Claim Denied On The Basis That You Are Likely To Require Care For A Very Long Time
- A Claim Denied For Technical Reasons Such As Incorrect Coding
- A Claim Denied Because You Are Not Home Bound
Arguments To Use Against An Insurer's Denial Of A Health Claim
A Claim Denied On The Basis That The Procedure Is Not A Covered Procedure
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An insurance company may deny a claim on the basis that the procedure is not covered under your particular policy. One way to do this is to call a procedure or treatment by a different name.
Of course, your first step is to call the insurance company and request an explanation for the denial.
If you still believe a procedure or treatment should be covered, call your state Insurance Department and ask how they would interpret the specific wording from the policy with respect to the treatment or procedure that is being denied. The Insurance Department's opinion won't necessarily be binding. However, if the Insurance Department agrees with you, it becomes a strong argument with which to return to the insurance company.
Try to get this opinion in writing. Even if the Insurance Department employee won't put the opinion in writing, be sure to get the name of the person with whom you speak.
The Insurance Department may insist you file a complaint before it will give you this kind of advice. If so, there are no apparent reasons to keep you from filing a complaint . Still, before filing, think through your situation to see if there any that apply to you.
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