Common Justifications for the Denial of a Health Insurance Claim

Wed Feb 7th, 2018 on     Health Insurance,    

Insurers — whether in the health insurance context, or some other context — will look for any possible justification to support their denial of a policyholder’s substantial claims, however legitimate those claims may be.  Recent scandals plaguing health insurers have shaken the industry to its core and revealed that many health insurers do not enforce their guidelines or properly supervise their assessors, which can lead to systemic wrongdoing.

If you have a legitimate health insurance claim that has been denied by your insurer, you may be entitled to damages on the basis of their wrongful denial.  With the assistance of a qualified health insurance attorney, you can gather additional evidence and repackage your health insurance claim, appeal the denial, or — ultimately — pursue trial litigation against the insurer to recover the compensation to which you are entitled.

Understanding the reasoning that insurers use to rationalize their claim denial is fundamentally important, as it highlights those issues that must be circumvented or challenged.  Consider the following.

Common Justifications for Claim Denial

Treatment Not Medically Necessary

Whether treatment is deemed medically necessary depends on a number of factors, from the language and provisions of the insurance policy, to the circumstances of your injury (and potential treatment thereof).  Each plan may differ in terms of its definition of medically necessary treatment, with some plans executing a broader construction, and some plans executing a stricter construction.  For example, your plan may require that only certain type of medical devices be use to treat certain conditions — if the medical device does not meet the strict requirements described in the insurance plan, then it may be used as justification to deny the health insurance claim (as the device is not medically necessary).

Policyholder Failed to Mitigate Damages

All policyholders have a duty to mitigate their damages, to a reasonable degree.  In the wake of an injury, for example, you must make reasonable efforts to minimize the possibility of suffering additional injuries and worsening your condition.  If you delay medical attention, and your condition worsens as a result, the insurer will almost certainly argue that they are not liable to payout for claims made on those subsequent injuries.  Failure to mitigate your losses will be used to justify the denial of your claim entirely, or in the alternative, to justify undervaluing your claim.

Coverage Exclusions Apply

Depending on your plan, certain coverage exclusions may apply.  Some plans will outright refuse to cover injuries that were caused by your intentional conduct.  For example, suppose that you engage in extremely reckless driving and total your vehicle, suffering significant injuries as a result — the plan might not cover such injuries.  When you enter into a health insurance contract, it’s therefore useful to have a qualified attorney assess the terms of the contract and what exclusions apply.

Waiting Period is in Effect

Florida law gives health maintenance organizations and employers the right to implement waiting periods for health benefits.  If you suffer from an injury, illness, or other condition during such time, you may have your claim denied.  Waiting periods are not all the same, however.  In some cases, the insurer may have to reimburse you for your expenses, so long as the treatment you received was medically necessary.

Consult With a Skilled Miami Health Insurance Lawyer

Here at Ver Ploeg & Marino, our attorneys have litigated numerous insurance disputes on behalf of policyholder-clients, helping them achieve a favorable resolution, whether in the form of a claim acceptance, settlement, or a damage award at trial.  We are committed to personalized advocacy, and to that end, we work closely with clients from the beginning of the engagement process to ensure that the desired results will be achieved.

Call (305) 5770-3996 to contact an experienced Miami health insurance lawyer here at Ver Ploeg & Marino today.  Your initial consultation is free, during which we will evaluate your claims and how best to proceed with resolving the dispute.

Super Lawyers
Florida Legal Elite
Top Lawyer - South Florida Legal Guide
Association of Corporate Counsel - South Florida Chapter
Back to top