Health Insurance Articles

When You Can Be Legally Denied For Health Insurance

2011-02-08

Health insurance is considered a necessity in this country with the rising costs of health care. This is why it is such a tragedy when people find their health insurance denied. It is important to know the rights that the consumers have to health care, but also the limitations as outlined by law. There are ways that people can be legally denied for health insurance that everyone needs to understand.

The most common reason that millions of people have health insurance denied is because of pre-existing conditions. In 45 states across the country, health insurance companies can deny provision of health insurance to those who have health conditions that exist before someone enrolls in an individual health insurance plan. Not only can these health insurance companies deny coverage, but they can charge extra for these conditions if they do choose to cover them. This type of discrimination in health insurance is common and has been used to save health insurance providers from legally having to pay claims.

Another reason that has been given for having health insurance denied is if the conditions that someone is seeking coverage for is not medically necessary. Necessity of medical care is an area that is often debated in the health insurance industry and insurance providers have expert opinions readily available to substantiate claims to how necessary conditions are. This is a legal reason for denied health insurance, but it is an area that is ambiguous and decisions of initial denial have been overturned after consumers have been able to prove that their procedures are medically necessary.

Another common reason for denied health insurance is that of a benefit that is not covered. A person might have otherwise intact major health insurance, but health insurance providers have the legal right to exclude conditions in the written policy. One example is in maternity benefits, where some health insurance providers will allow a woman to be covered for any ailment or condition with the exception of prenatal or postnatal care. This is perfectly legal for a provider to exclude coverage for such a common condition as long as it is outlined in the policy.

A final reason for denied health insurance is for treatment that is considered by the health insurance company to be experimental. There have been ways that consumers have gotten around this exclusion clause by showing treatment to be medically necessary or otherwise included in the policy. When faced with this denial or any other type of health insurance denial, a consumer should elicit the assistance of the state regulatory agency to understand the legal limitations of each unique governing authority. Health insurance is regulated by the laws of the state it operates in.