When the Insurance Company Denies Treatment: Your Options & Next Steps

Many people are forced to deal with insurance denials, even when there appears to be no legitimate reason. Understanding why your insurance company might deny coverage, and speaking with an experienced personal injury lawyer, can make it easier for you to review your options and determine next steps.

Why would your insurance company deny treatment?

Although every insurance policy and personal injury case is different, there are several common reasons insurers deny coverage for medical treatment, including:

• The insurance company claims that your treatment is not medically necessary
• The insurance company claims that your treatment is experimental
• The insurance forms contain billing or coding errors
• Your proposed treatment involves an out-of-network provider
• Your proposed treatment goes beyond the terms of your policy
• Your healthcare provider did not obtain pre-approval for the treatment you need
• Your proposed treatment exceeds the financial coverage limits imposed by the policy
• The insurance forms are incomplete or vague
• The insurance forms contain inaccurate information
• The insurance company states that your treatment is investigational and, therefore, will not cover it

Each one of the above can lead to a situation in which your insurer denies treatment. When your insurer denies treatment, you may not be able to afford the treatment you need. However, you may have other options, such as appeals or external review, depending on your plan.

What are your options?

Speak with your insurance company

Among all available options, if an insurer refuses treatment, the first step is to speak with your insurance company to learn why the claim was denied.

For example, if your insurance company denies a treatment request on the grounds that the treatment is “experimental,” you can ask for the basis of that determination, explain why you disagree, and dispute the insurer’s reasoning when preparing an appeal.

If you are not sure what to say to your insurance company, consider consulting with a personal injury lawyer who knows how to navigate these claims and may be able to assist or coordinate the appeal process.

Appeal the denied medical claim

Speaking with your insurance company can help reverse an insurance treatment denial. If it doesn’t, you can always appeal the denied medical claim, although appealing an insurance treatment denial is rarely easy. Follow your insurance company’s appeal process down to the letter. Be as thorough as possible and remain honest, respectful, and direct throughout the proceedings.

If you need assistance, you can work with a personal injury lawyer. They’re able to walk you through the process and file an appeal on your behalf.

Request a review of the denied medical claim

If your plan is subject to state or federal external review requirements, you generally must complete the internal appeal before requesting an independent external review, subject to applicable deadlines and exceptions. In limited urgent circumstances, such as when delay could seriously jeopardize your health, you may qualify for an expedited external review. For plans subject to external review requirements, an overturned decision is generally binding on the health plan.

What are the next steps to take?

When your insurer refuses treatment, there are a number of steps you may want to take:

1. Review the denial letter to determine why your insurer denied the medical claim
2. Gather all of the documents pertaining to your medical claim, as well as your insurer’s denial of the claim
3. Speak with your healthcare provider and update them about the denial
4. Contact your insurance company directly to discuss the denial
5. If the above does not resolve the issue, learn your insurer’s appeal process
6. Follow the appeal process and provide all required information
7. Provide additional information, if available, to further validate the need for your requested treatment.
8. Make sure to file the appeal before the deadline, as waiting too long can make the process more difficult
9. In the event that this appeal is denied, request an independent review of the denied medical claim
10. Review the process of requesting this independent review and follow it to the letter
11. Provide all of the necessary evidence, including documentation from your healthcare provider
12. Wait until you receive the final verdict from this independent review

Each of the above can help you obtain the treatment you need. To make this easier, you may want to work with a personal injury lawyer. Your personal injury lawyer can:

• Inform you of available options
• Help you contact the insurance company to seek a reversal of the insurance treatment denial
• File an appeal with the insurance company that may help you obtain the treatment you need
• Request an independent review of your denied medical claim if you’re eligible
• Gather and present evidence that supports each one of those options.

Speak with a Pennsylvania personal injury attorney today

Insurance treatment denial is far too common. We’re ready to help you. Contact us today to speak with one of our Pennsylvania personal injury attorneys. KBG Injury Law can help you better understand your legal options.