Common Reasons Claims are Denied

Common Reasons Claims are Denied

Unscrupulous insurance companies often attempt to deny health insurance claims by either delaying payment or making the process so onerous that the claimant simply gives up and drops the claim. This type of bad faith insurance behavior is more common than people want to think, and the following are some of the most common ways it manifests.

Patient Went “Out of Network”

Some insurance companies will act in bad faith by creating very limited networks of physicians for patients to see. When a patient seeks care from a doctor, not within the network, the insurance company can deny the claim. Moreover, should a listed doctor leave the network and fail to notify the patient they are no longer in the network, the insurance company can also use this reasoning to deny a claim.

Treatment was “Not Medically Necessary”

Even with a doctor’s advice and recommendations, insurance companies can deny insurance claims based on their perception of whether the treatment was necessary or elective. For example, they might accept that heart surgery was necessary but deny claims for postoperative therapy and treatment.

Treatment was “Experimental”

Many insurance companies have language tucked within their policies that allow them to deny claims for theoretical, experimental, or investigative treatments. In some cases, these exclusions cover medical therapies and treatments that have widespread support and approval from the FDA and within the medical community. For example, the insurance company might deny a claim for medication because of an off-label usage even though state law and FDA rules allow for it.

Treatment was “Cosmetic”

Insurance companies frequently deny claims for cosmetic procedures even if the need for cosmetic surgery follows the need for a medically necessary procedure. For example, a medically necessary cosmetic surgery might include breast reconstruction following a diagnosis of cancer and a mastectomy or skin grafting following severe burns.

Dealing with Denial

All claims denials should be accompanied with information from the physician clearly identifying the medical necessity of the procedure. It is advisable to conduct every stage of the appeals process in writing because this creates a written record that can be referenced in court should the appeal require legal action. This documentation can be used to establish the bad faith standards that were violated. A bad faith insurance attorney in Nevada can help draft the necessary communication and begin building a case to pursue a bad faith insurance claim against the provider should the appeal be denied by the insurance company.