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Why a medical claim may be denied

No one plans to get sick or develop a medical condition, but the reality is that these things happen and, when they do, the costs associated with medical care and treatments are often astronomical. Health insurance exists to help defray costs associated with medical care. For example, if an individual gets sick and needs to go to the doctor, his or her health insurance typically covers a portion of the expenses related to a doctor's visit or hospital medical tests.

What happens, however, in cases where a health insurance claim is denied? Can you imagine suddenly receiving a medical bill for thousands of dollars and learning your insurance provider determined that treatment for your condition wasn't medically necessary?

Health insurance providers may deny a claim for a number of reasons. In some cases, an insurance provider may determine that a test or procedure wasn't medically necessary. In other cases, a claim may be denied due to a clerical error or because a physician recommends a treatment that isn't understood by or included in an insurer's computer system.

When faced with a denied health insurance claim, Florida residents are encouraged to file an appeal. Often, individuals who appeal denied health insurance claims are successful in obtaining coverage. For example, an individual may be denied coverage for a medical condition that an insurance provider considers to be mild in nature. However, for this individual, a physician may determine the condition is life-threatening.

When appealing a denied health insurance claim, an individual would be wise to contact his or her doctor who can help explain and document why a test or procedure was necessary. Sometimes, an appealed health insurance claim may still be denied. When this happens and an individual is not able to pay for the medical services provided, individual healthcare providers and hospitals may choose to take legal action.

Source: NPR.org, "Patients Often Win If They Appeal A Denied Health Claim," Pauline Bartoline, April 14, 2014

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