When we are insured, we are guaranteed to receive compensation from the insurance carrier when we get injured or sick, provided that our conditions are specified in the plan as part of the coverage. We file for claims after receiving treatment so that we can be reimbursed for all the payments we’ve made.
In some cases, though, insurance carriers may deny claims. They dopeo this for various reasons, such as denying the fault of the party who has caused your injuries. When this occurs, it’s either the insurance carrier have misinterpreted the language of the insurance plan purposely to avoid paying claims, or you’ve missed the deadline for filing claims.
If you’ve recently been denied a claim and you suspect that the reason is the former, your insurance carrier may be acting in bad faith, so you must confront them with legal assistance from an experienced bad faith insurance lawyer.
That said, let’s identify the common reasons — other than bad faith — for denied claims and the ways to ensure that yours will be approved.
Common Reasons for Denied Claims
1. Denial of Fault
If your injury is a result of a personal injury case, you must prove the fault of the other party to their insurance carrier, or your claims may be denied. In a car accident, for example, the insurance carrier of the driver at fault must compensate you for your medical bills, but if they aren’t capable of paying you, they may attempt to deny the driver’s fault, arguing that you are also partially responsible for the accident.
2. The extent of Injury Denial
Some insurance carriers may deny the severity of your injuries, especially if its signs aren’t seen outwardly. They may even use statements from medical professionals to insist that the extent of your injuries isn’t what you claim it to be.
3. Refuting Causation
In the case of an injury that has more than enough evidence for claims, the insurance carrier may attempt to reason out that it was only due to a previous grievance or an existing medical condition, hence claims aren’t necessary.
How to Ensure Approval for Your Claims
Correct and complete information is vital to get your health insurance claims approved. The following are some of the crucial queries in the claims form:
- Your insurance policy number, group plan number, or member number
- Who received treatment (if it’s the primary insured or their beneficiaries)
- If the plan has coinsurance or dual coverage
- Purpose of the claim (e.g. accident or worker’s compensation)
As you prepare to file claims, here are the steps you’d be taking to ensure its approval:
- Obtain original itemized receipts from your doctor. This describes each of the medicals services you received along with their costs, as well as the costs of the drugs you’ve been prescribed with.
- Acquire your claim form. You can either get the copy from your insurance carrier or download it from their official website.
- Make copies. This will help eliminate errors in the claim process and make it easier for you to re-file if the carrier misplaces your form.
- Review and send. Ensure that you’ve provided complete and accurate information, then notify your carrier that you’ll be filing a claim. Find out if there are deadlines for filing claims to be sure that you’ll be submitting within the given time frame.
Recognizing Bad Faith
Denial is considered an act of bad faith if the carrier fails to respond to a claim promptly, whether or not it’s intentional. It’s also bad faith if the carrier failed to disclose policy limitations and exclusions before the insured made their investment.
Your claims should be approved when you’ve submitted complete and correct information, as well as evidence of another party’s fault, if necessary. Otherwise, you may file a lawsuit and be awarded compensation for damages.