Medical Devices and Health Insurance Denial

Thu Jan 24th, 2019 on     Health Insurance,    

Miami Health Insurance Lawyer

Though healthcare insurance denials are common, many policyholders are shocked when they are denied benefits for having received a medical device at the behest of their treating physician.  In truth, healthcare insurers are built to deny as many claims as they can reasonably justify.  They profit and thrive on the expectation that you will not challenge their decision and that they will “get away” with not having to pay out the benefits that you might be owed.

We can help.

If you’ve had your healthcare insurance claim denied on the basis that your medical device is not covered by your policy, or for any other reason, then you may be entitled to challenge their initial decision and secure benefits.  Contact Ver Ploeg & Marino, P.A. for further assistance with your dispute.

Let’s take a brief look at the basis for such denials.

Medical Necessity

Generally speaking, health insurers deny benefits for medical devices on the basis of medical necessity, which is a rather broad concept.  Every insurance policy is different, of course, and the definition of “medical necessity” can vary considerably from plan-to-plan.  Most share certain commonalities, however.

Determining whether a device is medically necessary requires a comprehensive evaluation of factors: whether the use of such device is clinically appropriate, whether it has been provided in accordance with generally accepted standards of practice, and whether it is no more costly than competing devices or therapies that could produce an equivalent result.

For example, suppose that you purchase a specialized walker that can be folded into several different configurations for easy storage and use.  The walker is costlier than most standard walkers, however.  Unless you can show that the additional functionality is medically necessary, your insurer is likely to deny benefits.

Specific Exclusions May Apply

It’s worth noting that many healthcare insurance policies feature explicit limitations on what sort of medical devices are covered.  Cheaper policies often exclude medical devices that are not “durable.”  This definition may vary, but generally it is meant to account for devices that can last for a period of years, can withstand repeated use, and that is only useful in the medical context.  A wheelchair is perhaps the prime example of a durable medical device.

Ambiguous exclusions may not be enforceable, so it’s important that you consult an attorney about your policy.  Florida courts interpret ambiguous properties in favor of the insurance policyholder, not the insurer, so coverage may be possible if the exclusion is written in a way that allows for multiple interpretations.

Contact an Experienced Miami Health Insurance Lawyer for Help

Ver Ploeg & Marino, P.A. is a Miami-based insurance litigation firm with extensive experience representing the interests of policyholders who are involved in disputes with insurance companies, including healthcare insurers.  Over the years, we have built a consistent track record of results.

If you’re ready to speak to an experienced Miami health insurance lawyer about your dispute, call 305-577-3996 or send us a message online to schedule a consultation.

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