When you are ill and a doctor recommends a course of treatment, you naturally assume that your health insurer will reimburse the cost.  That is not always the case, though, and it is not uncommon for benefits to be denied, especially if the costs are high.  Examples of types of claims that are frequently denied include:

  • Cancer care involving treatment such as stem cell transplantation, proton beam therapy, or newly developed high-cost medications;
  • Air ambulance transportation;
  • Residential treatment for behavioral health conditions; and
  • Emergency out-of-network treatment

Insurers even challenge emergency room visits if, after the fact, it appears such treatment could have been provided elsewhere.

Decisions about whether services are covered or excluded begin with the terms of the plan or policy, which all contain explicit exclusions for non-covered services that are not medically necessary.  Most insurers have also developed policies covering specific care or treatments, which can usually be researched on the internet.  Such policies quickly become outdated with new medical advances, though, and some policies are simply inconsistent with accepted standards of medical care.

Another major source of denials or inadequate reimbursement is the growing popularity of association or so-called short-term health benefits policies that do not have to incorporate essential benefits mandated by the Affordable Care Act (ACA).  If the premium cost for a policy appears too good to be true, be wary.  Consumers buying individual health insurance policies should always ascertain the coverage they are purchasing meets the requirements of the ACA.

How Can Insurance Benefit Denials Be Challenged

Just because an insurance company says no to a claim, that does not mean the insurance company’s decision cannot be challenged.  If coverage was provided through your employer, you automatically have appeal rights under the Employee Retirement Income Security Act (ERISA) if you work in the private sector.  Plans governed by the ACA are also mandated to require independent external review of benefit denials upon request.

When a doctor prescribes a drug or course of treatment that is not approved by insurance, the doctor should be prepared to justify the decision and may need to write a letter of medical necessity offering a rationale that not only explains why the treatment has been recommended, but also advises on why lower priced or less intensive alternatives are contra-indicated or would be ineffective.

Challenging health benefit denials can be extremely difficult, though.  Insurance companies have lawyers and other resources to defend their claim denials; and patients dealing with severe illness are usually not in the best situation to challenge claim denials on their own.  Keep in mind that insurance claims are legal claims – having an experienced and knowledgeable lawyer fighting for you is the best weapon you can employ.  We’re here to help.

-The lawyers at DeBofsky Sherman Casciari Reynolds P.C.

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