What Are Common Defenses Insurers Use in Health Insurance Claim Disputes?

When you file a health insurance claim, you expect the insurance company to pay for the necessary medical expenses. However, in many cases, health insurers may deny claims or refuse to provide full reimbursement for the care you received. Insurance companies use various defenses to justify these denials. 

Understanding these defenses and knowing how to respond can make a significant difference in the outcome of your claim. At BFH Law Group in New Orleans, Louisiana, we can help you overcome these challenges.

Pre-existing Conditions

One of the most common defenses insurers use to deny health insurance claims is the argument that the medical condition in question existed before the policy started. Pre-existing condition clauses are often found in health insurance contracts, particularly in individual health plans. 

These clauses state that the insurer won’t cover treatment for conditions that were diagnosed before the policy's effective date.

While the Affordable Care Act (ACA) has eliminated pre-existing condition exclusions for most types of health insurance, this defense can still arise in certain situations, especially if you're dealing with older policies or non-ACA compliant plans. 

Insurers may argue that your treatment is related to a pre-existing condition, even if your current medical issues are unrelated or were caused by a new event.

Remedies

If your health insurer denies a claim on the grounds of a pre-existing condition, a health insurance claims attorney can help you challenge the decision. Attorneys can review your policy, medical records, and any available documentation to prove that your current claim is unrelated to a pre-existing condition.

Procedural Defenses

Health insurance policies typically have strict timelines and procedures that must be followed when submitting claims. If these procedures aren’t followed correctly, insurers may reject your claim. Common procedural issues include missing the filing deadline, failing to provide required documentation, or submitting the claim through the wrong process.

Insurance companies may argue that the claim is invalid because it was filed too late, that necessary forms were missing, or that you didn’t follow their specific claims procedures. For example, some insurers may require pre-authorization before certain treatments, and failing to obtain approval could result in the insurer denying the claim.

Your Next Steps

A health insurance claims attorney can help you review the timeline and procedures for submitting your claim. They can assist in identifying where things may have gone wrong and work with the insurer to make sure that the claim is processed appropriately.

Lack of Medical Necessity

Another defense insurers often use is the argument that the treatment you received wasn’t medically necessary. Insurers rely on their medical guidelines or third-party assessments to determine whether a service is essential for your health condition. 

If they believe the treatment wasn’t necessary or if it falls outside of their approved list of treatments, they may deny coverage.

This defense is commonly seen in situations where patients undergo elective procedures, experimental treatments, or services that may not be explicitly covered by the insurance plan. Insurers may argue that the treatment was "cosmetic" or not "evidence-based," leading to a denial of the claim.

What Can You Do?

If your insurer denies a claim based on medical necessity, a health insurance claims attorney can help challenge the insurer’s decision. They can gather expert medical opinions, medical records, and supporting evidence to demonstrate that the treatment was, in fact, necessary for your health. 

A knowledgeable attorney can also assist in appealing the decision to get the coverage you need.

Policy Exclusions

Health insurance policies contain various exclusions that limit the scope of coverage. These exclusions may cover certain treatments, conditions, or services that aren’t included in your plan. For example, many policies exclude coverage for elective surgeries, alternative treatments like acupuncture, or specific types of long-term care.

When an insurer denies a claim based on a policy exclusion, they typically argue that the treatment you received falls into one of the categories excluded from coverage. This defense can be difficult to overcome, especially if the exclusion is clearly outlined in your policy documents.

Your Options

If your claim is denied due to a policy exclusion, a health insurance claims attorney can help you interpret the policy and determine if the insurer has applied the exclusion correctly. In some cases, there may be exceptions or opportunities to demonstrate that the treatment falls within the policy’s coverage.

Errors or Omissions in the Insurance Application Process

Insurance companies may deny a claim if they find that there were errors or omissions in the information provided during the application process. 

For example, if the insurer discovers that you failed to disclose important health information or made an error when filling out your application, they may argue that your policy is invalid or that they aren’t obligated to cover the claim.

This defense is often referred to as a "misrepresentation" defense. If the insurer believes that the misrepresentation is significant enough, they may attempt to rescind the policy or deny a claim.

Discover Your Rights

A health insurance claims attorney can help you understand whether a misrepresentation defense is valid. They can assist in determining whether the error or omission was minor and didn’t impact the insurer’s decision to provide coverage. If necessary, your attorney can work to have the claim reinstated or to negotiate a favorable outcome.

Fraud Allegations

In some cases, insurers may claim that the health insurance claim was fraudulent. They may argue that the services were exaggerated, that billing codes were falsified, or that the treatments weren’t actually provided. Fraud accusations are serious, and insurers often use them as a defense when they believe the claim was fabricated or intentionally misleading.

If an insurer suspects fraud, they may launch an investigation into your claim, which could delay payment or result in a complete denial of benefits. In some extreme cases, fraud allegations could lead to criminal charges.

How to Respond to the Situation

If you’re facing fraud allegations in a health insurance claim dispute, a health insurance claims attorney is crucial. They can help protect your rights, prevent the insurer from unfairly accusing you of fraud, and make sure that you have the support necessary to resolve the dispute in your favor.

How Can Working With a Health Insurance Claims Attorney Help You?

Dealing with health insurance claim disputes can be overwhelming, especially when facing these complicated defenses. Working with an experienced health insurance claims attorney can provide you with several benefits:

• Knowledgeable guidance: An attorney understands the intricacies of insurance policies and can guide you through the claims process, helping you avoid common pitfalls.
  

• Negotiation skills: Attorneys are skilled negotiators who can advocate on your behalf to make sure you get the benefits you need.
  

• Appeals process: If your claim is denied, an attorney can help you file an appeal, presenting evidence and making the necessary arguments to overturn the denial.
  

• Legal representation: If your dispute escalates to litigation, having a health insurance claims attorney on your side can make sure that your rights are protected throughout the process.

Having professional legal representation can increase the likelihood of a favorable outcome, making sure that you receive the coverage you need for your medical expenses.

Speak to a Health Insurance Claims Attorney

A health insurance claims attorney can provide you with the support needed to manage these disputes and advocate for your rights. If you’re facing a health insurance claim dispute, don’t hesitate to contact us at BFH Law Group. We’re proud to serve clients in New Orleans, Louisiana, as well as Houston, Texas. Contact us at BFH Law Group today.