What to Do When Health Insurance Fails to Pay for Health Benefits

According to USA Today, the average family health insurance policy cost more than $13,000 in 2009. With these premiums, in addition to deductibles, coinsurance and co-payments, policyholders expect their health claims to receive approval from the insurance company. When claims are denied approval, policy-holders have the right to a review process that can reinstate the health benefits they are entitled to.

Requirements

• Health insurance companies are required to provide coverage to their policyholders for all in-network services and all non-network emergency services without prior approval. Additionally, the companies cannot deny claims or rescind policy coverage based on minor application mistakes. Coverage may only be denied or revoked if the policyholder is found to have intentionally and fraudulently deceived the insurance company by lying or withholding important health information.

Private Appeals

• When a medical service is denied insurance coverage, you may appeal to the insurance company through customer service or via your insurance agent. The company is required to review the claim and explain its decision. Reviews must take place in a timely manner--72 hours for urgent care, 30 days for non-urgent care and 60 days for a service already received. The problem may be resolved with the company when the case is revisited.

Affordable Care Act

• In March 2010, President Obama signed the Affordable Care Act. Under this law, health insurance policyholders have the right to an unbiased review of health plan decisions with a government agency. In order to obtain an appeal, you must first appeal the coverage decision with the insurance company itself. If the decision remains the same, you have the option to seek review from an external source, and your health insurance company must provide you with the information and instructions for doing so.

Considerations

• Some coverage denials are due to simple billing problems or other careless errors involving either the insured, the medical facility or the insurance company itself. Also, insurance companies are allowed to deny you insurance coverage if you are found to have supplied fraudulent information on your application. This includes withholding information about a pre-existing condition or previous doctor visits, prescriptions or operations.

Prevention

• Prevent future coverage denials by being truthful with the insurance company about any medications you take, conditions that you seek regular treatment for and diseases that are a part of your family history. Check with your insurance company to find doctors and hospitals that are considered "in network." Also, be aware of exclusions in your policy. If your insurance company requires pre-authorization before a scheduled medical procedure, failing to obtain it could result in a denial of coverage.