Under What Circumstances Can Your Health Insurance Claim Be Reasonably Denied?

Feb 28, 2018 | Blog |

Insurers frequently deny health insurance claims, for a variety of reasons — some justified, and some with minimal basis in reality.  As a policyholder, it’s important that you recognize that your insurer is not your ally.  Throughout the claims process, your insurer may attempt to minimize their liabilities by consistently undermining the legitimacy and extent of your claim.  In some cases, your insurer may even unreasonably delay or otherwise interfere with the processing or payout of a health insurance claim.

The denial of your health insurance claim can put you in an unenviable position.  Substantial costs can accrue, and without the certainty of health insurance coverage, it may not be clear how you should proceed with treatment, if at all.  Fortunately, wrongful denial, delay, or interference may entitle you to sue and recover damages pursuant to Illinois law.  With the assistance of a qualified Chicago insurance attorney, you can challenge the actions taken by your insurer, whether through the claim appeals process or through litigation.

Common Justifications for Denial

There are a number of reasons that are commonly used by insurers to justify the denial of health insurance coverage with regard to your claim(s).  These include, but are not necessarily limited, to:

Medically Unnecessary

What is deemed “medically necessary” depends on the particularities of your health insurance plan, as stricter insurance plans may view certain treatments as medically unnecessary and may require that the patient stick to a narrower subset of acceptable treatments.  For example, if you are suffering from a severe degenerative knee condition and have to get surgery to install a metal plate for support, you may not realize that your insurer has a strict definition of what is medically necessary with regard to such surgeries.  Your insurer may require that the metal plate meet very specific requirements.  It is therefore good practice to consult with a health insurance attorney before undergoing major surgery to confirm whether your plan covers the treatment at-issue.

Treatment Not With an In-Network Provider

The insurer may decide to deny coverage due to the fact that the treatment provider is not in-network.  Though this may seem like an obvious and reasonable justification for denial, you may be able to counter this reasoning by demonstrating that you could not have obtained reasonable, sufficiently-specific care in a timely manner with an in-network provider.  For example, if all the in-network providers in your region had lengthy wait times, you could argue that you were forced to go out-of-network to obtain treatment.

Non-Standard Treatment

Non-standard treatments can be difficult to get coverage for, as you’ll not only have to show that the treatment is medically necessary, but also that it is the only alternative after trying various other standard treatments.

Various Exclusions

Insurers use exclusions to avoid having to payout for claims involving certain conditions, such as a long-term illness.  Exclusions vary depending on the insurance plan.  For example, many insurance plans will exclude coverage for pre-existing conditions that were not disclosed in the initial stages.

Ambiguous provisions often lead to confusion and are construed by the insurer in such a way as to justify their decision to deny a health insurance claim.  It’s important to note, however, that courts must construe ambiguous provisions in favor of the insured.  As such, challenging a denial — when an ambiguous provision lies at the core of the issue — may compel the insurer to reconsider their decision.

Contact an Experienced Chicago Insurance Attorney

If you have had your health insurance claim denied, it’s important that you consult with a qualified attorney as soon as possible, so that your case can be evaluated and pursued in a timely manner.  Here at Bryant Legal Group, P.C., our attorneys boast decades of experience representing policyholders in litigation against their insurers.  We are committed to personalized, results-oriented legal advocacy, and work closely with clients throughout the litigation process to ensure that they understand how their case is developing.

Call (312) 561-3010 to get connected to an experienced Chicago insurance attorney today.

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