Go to navigation Go to content
Toll-Free: 1-888-690-0211
Phone: (843) 277-6061
Shelly Leeke Law Firm, LLC

Top 5 Reasons Medical Benefits Are Denied and How to Fight It

In today's world, healthcare can be a frustrating and confusing area. For the common person, understanding your health insurance benefits can seem impossible. Onedenied medical benefits of the most confusing aspects of health insurance is understanding why a claim has been denied.


There are many reasons why a claim can be denied. Here are the Top 5 reasons:


1) The service is not covered under the policy.

2) The service falls under the "preexisting condition" exclusion.

3) The doctor has provided incomplete or improper documentation.

4) The provider is not in the policy's network of "approved healthcare providers" or "planned participants.">

5) The health insurance company feels that the patient has misrepresented themselves on the health insurance application and this misrepresentation is deemed to be material and untruthful.


Dealing with a health insurance company who has denied you benefits can be a daunting task.

Below are the Top 5 strategies to minimize your risk of denial:


1) Read your insurance policy. The best thing you can do as an insured is to read you insurance policy. The insurance company is required to provide you with a complete copy of your policy, but it is your job to read it. Don't rely on what the sales agent told you. If you have questions, consult with a independent, knowledgeable person in the health insurance field.


2) Don't lie on your application. It is very important that you be honest on your health insurance application. If the insurance company finds that you have misrepresented yourself, you could be stuck with the medical bills.


3) Use a healthcare provider in you network if required. If your health insurance requires you to use a provider that is in their network of providers, it is crucial that you verify that the provider you have chosen is included in this list.


4) Don't bother with "specialty policies." "Specialty" policies are written for very specific medical conditions, such as cancer, and consist of numerous loopholes and limitation. For the average person, "specialty" policies are worthless.      


5) Get everything in writing. Require that your insurance company provide you with their reasons for denial in writing. Once you receive this notice, write to the insurance company explaining all the reasons you feel the benefits should not have been denied. Phone conversations are never set in stone. Remember, if it's not in writing, it never happened.

Shelly Leeke
South Carolina Injury Lawyer

Live Chat