|  | Healthcare Industry | Health Insurance

What Causes Denial of Health Care Coverage?

If you have health insurance, denial of health care coverage can occur when requesting services or at the claims payment level. If you do not have health insurance, denial can be at the policy level, whereby the health insurance company denies you an individual health policy.

  1. Denial of Coverage

    • Individual insurance plans can deny coverage to a person and her family. Most denial of coverage is due to preexisting conditions. When applying for coverage, you must complete an application disclosing any known health conditions. If you do not list these conditions but seek claims reimbursement for services related to a preexisting condition after the plan is in force, the insurer may deny payment of those services. Health insurers may allow coverage for preexisting conditions, such as cancer or pregnancy, two medical conditions that often cause denial of individual coverage, for an additional cost.

    Medical-necessity Denials

    • Certain services require preauthorization by the health insurance company, such as specialist visits, hospitalization, surgery, diagnostic tests and behavioral health and substance abuse treatment. Health plan reviewers may deny requests for services deemed medically unnecessary, using established medical-necessity criteria.

    Administrative Denials

    • Health insurers also issue administrative denial of services or claims. One reason for denial is "benefits exclusion," in which a service is not covered by the health plan. For example, when a claim or request for infertility services is received when infertility is not a covered benefit for the member, a denial is issued. Another administrative denial reason is "benefits exhaustion," in which the member has reached his benefit limitation. For example, if the allowed number of physical therapy visits is 30, any claims or requests beyond 30 will be denied.

    Appealing a Denial

    • When a health plan issues a denial of care or claims, you have the right to appeal the decision. All health plans offer at least one opportunity to appeal. You can appeal by calling or writing the health plan and requesting another review of the denial decision, or by having your health provider or a legal representative appeal on your behalf. Some health insurers offer several levels of appeal, including reevaluations of denials by reviewers not employed by the health plan.

Health Insurance - Related Articles