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How to deal with health claim denial?

Procuring an insurance policy doesn’t guarantee that all your claims would be paid. A policy document normally describes the conditions which would be covered and which wouldn’t. Therefore, you should always read the policy paper thoroughly to make yourself aware of the terms and conditions of the insurance company. But, there are times when a claim may get denied wrongfully. And, you may then leave with the option either to accept the cost and pay yourself or fight it back.

Know your rights!!

When it comes to fight a denial, knowledge would be your key. If the insurance company decides to deny a claim they would also issue a claim denial letter citing the clause from the policy. Therefore, it’s important that you know what your policy offers.

Ways to avoid a claim denial

• Review the policy time to time to make sure you have the coverage you want. If there are ambiguities regarding coverage, ask the agent to clarify it for you. You are entitled to proper explanation regarding benefits.
• Make yourself aware of the limitations of the policy. If your policy practices referral system, make sure that you obtain it before seeing a specialist. Also keep yourself updated with availing the services of out-of-network physicians.
• Make sure that your doctor understands the coverage of your policy. Often the doctors have to deal with various insurance companies and therefore it isn’t possible for them to remember each and every policy details.
• Save the documents of the treatment that you have received. It’d help at the later stage of disputing with the insurance company.
• Some policies would have a time limit within which a claim needs to be filed. Confirm that the doctor’s office send the claim to the insurer immediately.

But, what would you do if your claim gets denied?

Inspite of your best efforts your claim may still get denied. What would you do if such a situation arises?

• Call up the insurance company and speak to the customer care representative if you feel that the claim was wrongly denied. Many a times a claim may get denied because of administrative errors and a call to the insurance company can sort the matter out.
• If the problem persists, ask the insurance company to send you customized bills. Check if the list has listed services that were not rendered to you. If such a thing has happened, take-up the issue with the hospital or the doctor’s office.
• Ask for a formal review of the claim when the denial seems legit but you still feel that it should be covered. Most of the states have a time limit within which one is required to request for review.
• When everything else fails your option would be to contact the state insurance department. Every state has definite rules to deal with such situations and most of the times these policies would favour the customers.