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The Most Common Health Insurance Related Disputes

If you have forwarded your claim for health insurance benefits and it has been denied unjustly or in case you are involved in a dispute with your health insurance company owing to a wrong action, you can approach an insurance claim lawyer for help. When you buy health insurance, whether a private plan or an employer-sponsored one, you expect that your health insurance company will pay for your medical expenses, except deductibles and copayments.

However, if your claim gets rejected by your health insurance company or it offers you an amount of money that’s nowhere near the actual value of the claim, what are the steps you can take? What are the most common grounds on which your health insurer can deny your claim? Find out.

What Happens If Your Health Insurer Denies Your Claim?

If your health insurance company denies your claim or offers to pay an amount of money lesser than the actual value of the claim, you will have to pay for all your medical expenses. That might force you to face a big financial obstacle and even bankruptcy. The worrying factor now is that the health insurance providers and the policyholders are getting involved in disputes too frequently.

Disagreements happen when health insurers deny coverage of services the policyholders have received. Disputes can also happen due to the health insurers refusing to approve a procedure, a visit to a doctor, etc. When you disagree with a decision taken by the health insurance provider or want to dispute a health insurer’s charge, you need to know the proper steps. But first, know the grounds on which your claim can be denied by a health insurer.

Common Grounds for Denials

The common grounds on which your health insurance provider can deny your claim can be of various types. One, the medical care that you availed yourself was not required or necessary. Two, you don’t have the eligibility to avail of the benefit. Three, the treatment you received was experimental. Four, you are suffering from a pre-existing condition. Five, it’s the responsibility of another health insurer to pay for your medical procedure. Six, you didn’t take any prior consent for your medical treatment. Seven, if the medical care that you took has already been provided.

What Steps Can You Take When There is a Health Insurance Dispute?

Before you apply for a health insurance policy, you should know what your health plan will cover and what it will not. You must understand the procedures you can avail to comply with your health policy and receive the coverage you are entitled to. If you are fully familiar with the minute details of your health plan, you will automatically come to know whether your health insurance complaint is legitimate or not. In case it is legitimate, you can point out the section of the policy that proves you are right and the health insurer is not.

If you want to challenge the health insurer’s decision not to provide coverage for your medical care, initiate the procedure by approaching the claims representative who has denied your claim. You can also contact the customer service department of the health insurance company. Aside from that, you can also ask the company supervisor to intervene. Rejecting your claim can be the company’s mistake. In such a case, the company personnel might reverse the charges or approve all the services that the company denied in the first place. If the reversal doesn’t happen, you can ask the health insurance company for a written explanation stating why the claim was rejected or why the company decided to deny the coverage.

What To Do If the Company Denies Your Appeal?

In case the health insurer denies your appeal, you owe a full explanation. Also, you can take legal action right away. If the denial was a mistake or the company violated the terms and conditions of the health policy, you can take help from an insurance claim lawyer.

An employer-sponsored health plan is governed by the Employee Retirement Income Security Act of 1974. As per the restrictions laid down by the ERISA, you may sue for the benefits of the health policy, the fees of the attorney, as well as interest on the benefits past or due benefits.

Never accept an amount of money from the insurance company that is not full, fair, and reasonable compensation.

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