Top 10 Reasons For An Insurance Claim Denial Letter

In the aftermath of sustaining an injury, victims should be able to count on their insurance carrier or the insurance carrier of an at-fault party cover their expenses. This includes medical bills, lost income, pain and suffering damages, as well as other injury-related expenses. However, there are times when an insurance carrier denies a claim. Below, we review 10 reasons that a carrier may send an insurance claim denial letter.  Keep in mind that there are various types of insurance claims, and these reasons for denial may not apply to all of them.

1.      Paperwork errors or mix-ups

A claim denial letter could be sent for something as simple as your doctor putting the wrong name on one form or a mistake in the medical coding sent to the insurer.

2.      You were partially or wholly at fault for the incident

It is important to understand the terms of your policy. In many cases, if you were engaged in behavior that would void your insurance coverage, the insurance carrier is not required to pay the claim. For example, if you were driving while intoxicated and get into an accident, your insurance coverage will likely be voided. If you allowed an unlicensed driver to operate your vehicle, the insurance company may have reason to deny your claim. These are just a few examples of how are you may be at fault for the incident.

3.      You did not receive a medical evaluation

It is vital that you seek medical attention after sustaining any injury. Without an immediate medical evaluation of your injuries, it could be difficult to prove that they were the result of the incident in question. It is important to remember that some injuries do not show signs or symptoms until well after an accident occurs. This is why it is important to seek medical attention, even if you do not feel any pain after an accident.

4.      Questions about medical necessity

An insurer may believe your claim is not medically necessary. They may say that you do not actually need the requested service or that you have not shown enough proof that you need the medical treatment requested.

5.      Cost control or claim exceeds maximum coverage

An insurance carrier may want you to try a less expensive option than the one requested before approving the more costly treatment plan. An insurance carrier will also not cover claim amounts that exceed the maximum coverage agreed to in the policy.

6.      The service is not covered under the plan

It may be the case did the requested medical service is not covered under the insurance policy. This is often the case for cosmetic surgeries or treatments not approved by the FDA.

7.      Provider network issues

If you received medical care from a healthcare provider outside of the managed care system of your insurer, then the insurance carrier may deny the claim. In many cases, an insurance carrier only pays for coverage from selected doctors and facilities that are part of their network.

8.      Missing details

It could be the case that there was insufficient information provided with your claim or with the pre-authorization request. For example, you may have requested an MRI on your shoulder, but the doctor’s office did not send any information about what was actually wrong with the shoulder.

9.      You did not follow the health plan’s rules

Each health insurance plan has certain rules in place. For example, if your health plan requires that you get pre-authorization for a nonemergency test, but you get it done without the pre-authorization, the insurance carrier may have the right to deny payment for the test.

10.  You missed the required deadlines

There are various deadlines in place for reporting an injury to the insurance carrier. It is vital any injured party notify their insurance company in a timely manner.

If you believe your insurance claim has been unfairly denied, contact one of our Chicago insurance claim denial attorney to discuss your options.