Health Insurance FAQs

Health insurance claims are denied on a regular basis. According to a recent study, nearly 20 percent of all health insurance claims sent to non-Group qualified health plans offered on HealthCare.gov are rejected in the United States. The main reasons for denials are lack of information or incorrect information on the claim forms, insufficient coverage, preexisting conditions, and exceeding the policy limits. In some cases, the insurer might deny the claim if they think the medical care was not medically necessary.

You can fight a denied health insurance claim by sending a letter of appeal directly to the insurance company outlining your position and requesting an internal review. In some cases, they may be willing to reverse their decision. If they are not, you may need to take additional steps, such as requesting an external review with your state at no cost to you. In Wisconsin, for example, the Office of the Commissioner of Insurance reviews health insurance denials and disputes. Seeking legal assistance from a bad faith insurance lawyer can also help speed up the process and ensure you receive the maximum amount of compensation possible for your claim.

Health insurers may deny a claim due to errors in medical records or if they believe the treatment is not covered by a policy. A treatment may be uncovered because it was out-of-network, lacked pre-authorization, is deemed to be “cosmetic” or “experimental” in nature, or a similar reason. If your claim is denied and you believe your health insurance company is in the wrong, you may be able to dispute the decision with help from a lawyer.

Many insurance companies have a clause in their policies that require you to file an appeal within one year from the date of the denial. The statute of limitations for filing a bad faith insurance lawsuit varies state to state with some states requiring you to file within one year. This means that you should hire an insurance dispute lawyer as soon as possible to make sure your rights are protected.