Why are health insurance companies denying claims?
Health insurance companies are denying claims for a number of reasons, including exclusions, fraud, misinformation, and clerical errors. When you pay premiums for insurance coverage, you probably expect that your claims will be paid automatically. That is not necessarily the case!
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If your health insurance company denies your claims, their reasons may be legitimate. Other times, their reasons for denying your claim may not be legitimate. When you receive a denial, look over the letter carefully to find out what the reasoning was for the denial. If it doesn’t seem right and you don’t agree with the assessment there are ways to fight the denial.
What are health insurance policy exclusions?
When you apply for health insurance, you are required to answer many questions about your past medical care and conditions or illnesses you have had. The insurance company looks over your application very closely and determines if you are someone who they want to insure.
Sometimes an insurance company will accept your application and grant you coverage but put certain exclusions on your policy. Exclusions are services and care that the policy will not cover. Often if you have a pre-existing condition it will be excluded on your policy. This refers to a condition that you have previously been or are currently being treated for.
Even if you don’t have a pre-existing condition, there are other common exclusions that may be contained on your health care policy. These may include:
- Private home care, pregnancy
- Health insurance for cosmetic surgery or reconstructive surgery
- Behavioral problems
- Experimental drugs or treatments
If you try to get paid for any of these exclusions your claim will be denied. Look over your policy carefully. Make sure that you are aware of any treatment or condition that is excluded in your plan and therefore not covered by your insurance company.
Each state has their own mandates in regards to exclusions. This means it is possible some common exclusions may not be allowed in your state. If this is the case, your health insurance company must pay for them. To reach your state insurance department, go to the National Association of Insurance Commissioner’s website.
Do misinformation and clerical errors matter?
Claims may be denied because of a clerical error in the health insurance claims processing, or incorrect information on the claim form. If your doctor’s office filled out the claim and submitted it for you there is a chance that they got something wrong on the form that caused the claim to be denied.
This could be for simple reasons such as the wrong birth date, incorrect member number, or wrong service or diagnosis code. If this is the reason your claim is denied it is an easy fix and can be resubmitted. This is why it is important to investigate the reasons for the denial.
What constitutes fraud in terms of a claim denial?
One reason why your claim may be denied is because some type of health insurance fraud was found. If it is found that you have a pre-existing condition that you did not admit to in your application, it may be considered fraud. If you submit 
a claim for medical services related to this condition and the health insurance company finds out it is a condition you hid when you applied, your claim will probably be denied and your policy may be cancelled.
Fraud may also be found to be committed by a medical provider. If he or she purposely puts an incorrect code on the claim form or misrepresents the facts in any way, your claim will be denied. If you lie in any way in order to get insurance coverage and you are found out, you will be investigated and possibly convicted. This will affect you much more than just having a claim denied.
For more information about insurance fraud you should visit the website for the Coalition Against Insurance Fraud.
What if you feel your claim is unjustly denied?
If you feel that the insurance company denied a claim unfairly, you can appeal it. Investigate the reasons for the denial and write a letter stating why you believe the ruling to be unjust. Include as many details as you can and send it into the insurance company.
If the insurance company continues to deny your appeal you can submit the same information to your state insurance department. The state insurance department will perform its own investigation of the claim and subsequent denial.
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