When Can Your Medical Insurance Deny a Claim?

Your medical insurance covers the cost of medical services and procedures, including routine and emergency care. A physician or medical facility submits a claim to your insurance when you receive a service, and the insurer then pays the medical professional. Some situations allow your insurance company to deny all or part of the claim, leaving you responsible for the full medical bill.

Clerical Error

• A clerical error on your paperwork can cause your claim to be denied. Your insurer has the right to deny your claim if information on the physician's paperwork or your forms is incorrect, caused the insurer harm or delayed the company's investigation of the claim. The insurer, however, still must pay a valid claim once the error has been corrected if you didn't cause the insurer harm or delay an investigation.

Vague Description

• A claim can be denied if the insurer cannot get verification of the exact medical services performed. A health insurance company usually contacts your medical provider in writing if a claim was vague or missing information is submitted before denying to pay. The insurer can deny the claim if your physician fails to provide the information requested, such as on which area of your body a procedure was performed.

Services Not Covered

• Your medical insurance does not cover all situations. Some procedures, such as plastic or elective surgery, may be excluded. Other non-emergency services must be pre-approved by your insurer in writing or require a referral from your doctor. The company can deny a claim for a service that is expressly exempted from coverage in your policy, or requires a pre-approval or a referral that you failed to get.

Unreasonable Fees

• Health insurers are permitted to have a schedule of average medical fees for various services performed in your area. Your claim is denied in part or in full if your physician's fees are exorbitant when compared to your area's average. You may be able to appeal a claim denial based on unreasonable fees if unexpected complications with the service you received arose and are responsible for the higher cost.

Pre-existing Condition

• Services for a condition you had prior to obtaining medical insurance are usually not covered initially. The insurer has the right to investigate and deny claims regarding a condition within the first two years of your coverage, but only if the company has a valid reason to assert the condition must have existed before your coverage started.