Why do Health Insurance Companies Deny Claims?

If you were involved in an accident or just developed some illness, your doctor will recommend a course of treatment. And you expect your health insurance cover to reimburse the resources you spent during treatment. In such a situation, having your claim denied is enough to make you feel like you’re sick all over again. This is worse for patients with substantial medical bills.

Fortunately, you are entitled to an explanation from your insurer. This usually comes in the form of EOB (Explanation of Benefits). If your claim was denied, talk to an experienced CIGNA disability attorney to get detailed information about why your claim was denied and whether or not you can appeal the insurance company’s decision. Here are the top reasons why health insurance companies deny disability claims and other medical-related claims.

1. You used a healthcare provider who is out of your insurer’s network

If your insurer is an exclusive provider organization or a health maintenance organization, your health insurance claim may have been denied for using healthcare services outside of the policy provider’s network for healthcare. That means you shouldn’t use a healthcare provider who has not agreed to your insurer’s terms and means of payment.

So, if you received nonemergency or elective care and didn’t have out-of-network benefits, your insurer may deny your claim. That means you must pay your medical bills.

2. Your charges are not covered by your health insurance policy

It’s possible that the medical procedure you had isn’t covered by your healthcare policy, even when you think it should have been. Check your policy carefully as some healthcare insurance plans don’t cover some categories of healthcare. For example, most health insurance policies don’t cover dental surgery and infertility treatments.

3. A pre-authorization or referral was necessary

Medical procedures such as MRIs and CT scans usually require a pre-authorization. That means your doctor must request on behalf of you, the patient. Sometimes, your insurer may just ignore the fact that you didn’t have the authorization, while in other cases, your health insurance claim will be denied afterward.

However, if your claim was denied, but a specialist (your doctor) had ordered the tests, request the doctor to contact your insurer on your behalf.

4. Your medical bills went to the wrong health insurance provider

If your doctor’s healthcare facility didn’t bill the right insurance company, then your claim will be denied. Besides, you must ensure that you have an active policy. Note that having two policies could also be the reason your claim was denied. For instance, if you have healthcare coverage through your employer and your partner’s employer, this will cause confusion during billing.

Therefore, you should make sure you have a single health insurance policy and that your insurer has an up-to-date file for you.

Understanding the reasons your health insurance claim could be denied can help you avoid the related mistakes. To be on the safe side, consult with a lawyer when filing a health insurance claim.