You buy health insurance partly to relax about rising medical costs since a good healthcare plan pays for expensive hospital visits. However, some claims get denied for various reasons, and no money is paid out. You still have the opportunity to appeal when that happens, which the following explains.

Top Reasons a Health Insurance Claim Gets Denied

  • Incomplete or missing information on the claim
  • The plan does not cover the claim
  • Medical treatment is determined to be unnecessary
  • Loss or damage costs exceed coverage limits
  • Drug or therapy is not included in your health plan
  • Use of out-of-network services

What to Do if Your Claim Is Denied

The first step, if you receive a denial notice from your health insurer, is to understand why this action occurred. The appeal process is only worth it if you believe the decision was made in error. If it’s clear that the policy doesn’t cover your claim, there’s nothing you can do or say to overturn the decision.

Once you determine a proper appeal, compose a clear appeal letter explaining your medical condition. Make sure you provide data from a medical professional that supports your claim. Be aware of the deadline to appeal so that you avoid a late submission. You must follow the appeal process precisely, and all your information must be accurate to prevail with an appeal.

Appeal Letter Tips

  • Opening statement – Briefly state why you are appealing and the reason the claim was denied. Be sure to include the claim number. Don’t make it a dissent letter. Just stick with the facts. Keep the information relevant to your claim.
  • Health condition explanation – Summarize your health history and current conditions. Avoid leaving out minor conditions, as you should be forthcoming about the full range of your health issues. Be clear about why you seek treatment and believe it’s medically necessary. Mention treatments you’ve tried that haven’t worked.
  • Doctor’s note – Ask your doctor to provide a note that supports your reasons for seeking treatment. Any other medical documentation from a health institution may help your case.
  • Send by certified mail – If the appeal is not accepted online, the best way to submit it is by certified mail, which gives you the proof you sent the appeal by the deadline.

Odds of a Health Claim Denial

The odds favor health insurance policyholders regarding the percentage of approved claims. According to insurance industry data, in 2019, only about 17 percent of in-network claims were denied. The highest average claim rejection rate was for catastrophic policies, which accounted for 20 percent. However, different insurance companies issue different percentages of denials, which range from under 1 percent to over 50 percent.

If you need help understanding your health insurance policy, or if you want to start a new one, contact us today. Our experts at Weaver & Associates will be happy to assist you in creating a customized health insurance plan.