It is no secret that health care costs in Texas are high and increasing each year. Without health insurance coverage, a single illness or injury can lead to financial ruin.
Families pay insurance premiums each month expecting coverage when they become sick or injured. So what do you do when an insurance company refuses to pay for your medical care?
Denied insurance claims
Unfortunately, insurance companies do not always approve payment for a policyholder’s health care expenses.
An insurer may say a particular treatment is experimental, not covered or required pre-authorization. Regardless of the reason for denial, the result is the same: the policyholder is on the hook for an enormous medical bill.
When an insurance company denies a claim, a policyholder has the right to appeal the denial.
First, a policyholder can file an internal written appeal with their insurance company, which the insurer by law must review and decide within specified timeframes.
Second, a policyholder can also request an external review by an independent third party if an insurer denied a claim based on certain criteria, such as the treatment being experimental or medically unnecessary.
An expedited appeal may be available in circumstances in which a coverage decision is urgent.
Appealing the insurance denial
Appealing an insurance coverage decision can be a complicated procedure that inherently favors the insurance company. The insurance company wrote the policy and employs professionals to represent their interests.
For these reasons, policyholders facing a denial should strongly consider retaining a knowledgeable attorney to help level the playing field.
Failure to file appropriate paperwork or comply with deadlines can result in forfeiture of the right to appeal.
Considering the enormous costs of health care, it is important that policyholders have assistance through the complex process of appealing a health insurance denial.