What Are Health Insurance Companies Obligations?

health insurance company obligations claim denial

When it comes to health insurance there are so many things that fall into that gray area that is hard to define. For the average person, understanding health insurance can be, at best, a struggle that they have to surmount. That being said, if you are denied health insurance or a claim is denied, you do have the ability to hire a denied health insurance claim lawyer to help fight your case. 

What Are Health Insurance Companies Required To Do? 

Health insurance companies are a company like any other that deliver or provide a service to those customers that work with them. They are required to do certain things and are required to provide certain things to their clients in order to not be in violation. Health insurance companies are not required to provide insurance to every person that applies for coverage. 

They are not, however, allowed to discriminate or refuse service or coverage to people based on sex, age, race, religious beliefs or sexual orientation. They are required to view each application with a non- bias and then go through and either approve or deny coverage based on what the application contains. 

Most insurance companies are going to be loath to cover those that have pre-existing conditions but if the company is providing coverage for state or federal insurance that is free, they cannot refuse coverage based on any pre-existing conditions. 

Health insurance companies are only allowed to deny coverage or deny claims after they have been thoroughly vetted and looked at and if the person who had the claim decides to appeal, they must state the reasons for denying the claim. 

All health insurance companies are also required to have an adequate coverage network. This is to say that they cannot have a very narrow number of providers and must provide their clients with a larger pool of doctors or offices where they can seek help and can seek care. This is to prevent insurance companies from narrowing their provider pool so much that the insurance is basically useless, and the client cannot find a doctor to use it with. 

Health insurance companies are in place to protect those people that hold policies and to help pay for the cost of care so that they can live a happy and healthy life. Health insurance companies must also provide their clients with a clear list of doctors where their insurance can be used, a list of services and procedures that are covered by their policy, as well as a detailed list of what the policy actually covers and what it is going to pay for should the client decide to use it. 

Can An Insurance Company Deny Any Claim? 

While a health insurance company does reserve the right to deny claims, they do have to provide some basis for their denial for a few different reasons. If an insurance company seeks to deny a claim, they do need to take the time to provide the provider and the policy holder with information about the denial and why the claim was pushed back. 

They may also be required to cite where in the policy it states that the claim can be denied and what part of the policy states why this particular claim is not going to be approved. Health insurance companies are a company that depends on their customers and as such, they do bear a burden to explain things to their clients. 

So, what can you do if a claim is denied, and you feel that it should have been approved and that it was wrongly denied? The best thing to do in cases where your claim is denied, and it should have been paid is to first and foremost contact the company and see why they denied the claim. They should have to tell you about why the claim was denied and see what supporting information and evidence they have for the denial. You may also want to contact the doctor office or healthcare facility where the claim was filed so that you can see how it was billed and how it was sent through to see if there is any reason why it might have been denied. 

If this does not work, hiring a lawyer might be a good option. Hiring a lawyer is a great option as it does help you to get your claim seen, get it paid possibly, and to ensure that you are treated fairly and that your health insurance company is being held accountable and that they are doing what they promise their clients they are going to do. 

Health insurance companies have a duty to their customers and do need to work to ensure that they are doing what they can for their clients, that they are working toward ensuring that their clients are well cared for, and that they are providing services that are going to be useful and helpful to their clients. It is the duty of the health insurance companies to provide a service to customers. 

Health Insurance Company Claims Conclusion

The entirety of health insurance can be difficult, it can be hard to understand, and it can be challenging to get the most out of it. If you feel that your health insurance company is not doing all that they can to make sure that clients are well cared for. You cannot go without health insurance and making sure that you are working with your health insurance can make a difference. If you feel your health insurance denied a claim wrongly or that you are not being given the most from your health insurance, take the time to contact a lawyer to find out what can be done and to start a law suit if need be.

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