Even though your policy may appear comprehensive, denials for medical care claims are common. Sometimes this only reflects missing information or incorrect documentation. Sometimes the policy does not cover certain types of care. This is often a matter of interpretation of your specific care needs. If this is the case, you will need to go to bat along with your doctor or other health care provider to establish that your care should be covered even though the insurance company's agent interprets the policy as appearing to exclude it.
Pre-Existing Condition Your claim may be denied if your medical condition existed before you became eligible for or bought your policy.
Non-Covered Benefit This is usually explained in the section of your policy that lists illnesses or services excluded from coverage. Because of the possibility of non-covered benefits, it is a good idea to check your insurance plan before any treatment or tests are ordered. Some treatments are covered only when given or administered in the hospital, for example. In such cases, you or your physician's office may be able to make specific arrangements for outpatient coverage in lieu of hospitalization. Services may actually be cheaper that way.
Not an Authorized Provider Many insurance plans require that you use providers in their network. Specialists usually require a referral for a consultation and all subsequent treatment. Failure to go to contracted providers with a written referral can result in a complete denial of all treatment provided.
