Your doctor is recommending the best treatments you need to get rid of ailments, but your insurer denies paying you for the treatment. Nothing can be more disturbing than the situation where you neither opt for an alternative treatment nor change the insurance policy. Refusing to pay you clearly states that your treatment stays out of the coverage area given by your company. Some health insurers, though, make mistakes and illegally deny paying you. In this respect, specific claim procedures are there that help you get your money. There are several reasons why your health insurer refuses to pay you in needs. The content brings out in which circumstances you company deny paying you. Read the content carefully.
You need is not covered by the health plan your purchase
Your insurer can reject your claim on the basis that it does not come under the policy you purchase. Insurance policies come up with certain terms and conditions that need to be agreed by you. The company has a clear understanding of what are the things you get. This is why purchasing a health insurance is not an easy task. Read the guidelines thoroughly and ask for help in case of any doubt. If your company illegally denies your claim, check the terms and complain to the concerned authority.
The treatment carried out by out-of-network hospitals
Insurance companies have empanelled hospital list, and taking medical care from one of the network hospitals makes you eligible for reimbursement or compensation. If your treatment is done by a medical centre out of the network, companies have the ground to reject your request.
In this case, you can fight hard with the company to get your treatment amount. If you can successfully prove that no empanelled hospital can treat the ailments you have, the company is bound to pay your money. In case of an emergency, you can get medical attentions from a close health care centre rather than the network hospitals.
Claim can be rejected on the ground of medical necessity denial
Claim or preauthorization can be denied by your company if it thinks that the medical treatment was not necessary for your health. Medical necessity denial has many terms and conditions to read. The core thought behind is that your company simply says the treatment recommended by your doctor is not necessary. Understanding the concept will help you prove the company wrong and makes you able to incur the amount from your insurer.
Misconception of the health insurance cuts down the benefits
A clear understanding is always needed to purchase a health insurance. Any ignorance costs you severely when you are in need. The complex health care system keeps many gaps in providing comprehensive details of the benefits and coverage area of a health plan. These gaps need to be eliminated to take the complete benefits of the coverage you purchase for you and your family. There must be a free flow of information between you and the insurer and vice-versa.
Your hospital stay is termed as observation stay rather than inpatient one
You get hospitalized in two ways – inpatient and observation. Many companies will compensate you only if it is an inpatient hospitalization. If it is an observation purpose, companies would refuse to pay the amount. The rules and regulations broadly present in which cases are eligible for getting the compensation. Know the areas that are excluded by your company even before the benefits. This will lead to purchase the right plan where claim denial is less expected.
The above-mentioned reasons state you why your company refuses to pay for your claim. The only solution is getting complete information about health insurance with an understandable knowledge about inclusions and exclusions.