For What Reasons Are Health Insurance Claims Rejected?

A number of health insurance options and policies are available to consumers in California, but there are also a variety of ways that a health insurance company can deny a claim. If your own health insurance claim is denied, you will need the advice and services of a California health insurance claims attorney at the McKennon Law Group.

Health insurance claims are often exceedingly complicated. Whether you need a surgical procedure, a medical device, or a prescription filled, it can be difficult to know whether your health insurance company will cover your claim. One research study indicates that almost a quarter of U.S. consumers simply avoid seeking medical care because they do not know what their health insurance covers.

The McKennon Law Group Will Fight for Your Rights

If you assumed that your health insurance company would cover a doctor’s visit, a surgical procedure, a medical device, or a prescription, and your claim is denied, that denial is not necessarily final.

If the insurance company made a mistake – or violated the terms of your health insurance policy – a health insurance attorney at the McKennon Law Group can fight for your rights and for the insurance compensation you need.

We are skilled, aggressive, effective attorneys who have represented hundreds of clients throughout California and across the United States for over seventy years. We bring that experience to every health insurance case and client, and we are skilled at resolving even the most complex health insurance claim disputes.

Why Are Health Insurance Claims Denied?

Health insurance companies reject insurance claims for a variety of reasons, but the most common reasons for denying what may be a legitimate claim are:

1. A procedure, treatment, or medical device is deemed “not medically necessary” by the insurance company even though your doctor may have recommended it.

2. A procedure or treatment is deemed experimental or investigatory and is excluded from coverage.

3. You are diagnosed with a “nervous or mental” disorder that is excluded from coverage.

4. The procedure, treatment, or medical device is not deemed “customary or usual” and is excluded from coverage.

5. The expenditure for a procedure, treatment, or medical device was not pre-authorized, or some other policy exclusion applies.

When Can You Sue a Health Insurance Company?

If a health insurance company denies your claim in bad faith, you may sue for the expenses covered by the policy, for “consequential damages” (damages caused by the company’s bad faith), emotional distress, punitive damages, attorneys’ fees, and interest on past-due benefits.

If your health insurance is a group policy obtained through your employer, that policy is probably governed by the Employee Retirement Income Security Act of 1974 (ERISA), and you may sue for the expenses covered by the policy, attorneys’ fees, and the interest due on unpaid benefits, but bad faith damages are not available with respect to policies covered by ERISA.

It Costs Nothing to Learn More

You can learn more about health insurance claims and your rights by scheduling a legal consultation – with no cost or obligation – with a California health insurance claims attorney at the McKennon Law Group. Call us at (800) 682-4137, or you can reach us online using the contact form on this website. The offices of the McKennon Law Group are located in San Francisco, Los Angeles, Newport Beach, and San Diego.