If you have had your insurance claim denied, you know how frustrating it can be. The insurance company may deny your claim when you are seeking pre-authorisation to receive services. They can also refuse to pay for treatment, a test or a procedure after you have had it done. You could end up feeling desperate and convince yourself that there is nothing you can do. You are not alone as this is a common feeling. A large percent of denied insurance claims are never appealed. However, in some cases, 70 percent of those that are appealed succeed. This shows how important it is to pursue an insurance claim even after an initial denial.
Reasons for Denial of Insurance Claims
There are many reasons why your insurer may deny your claim. Some reasons are simple and easy to fix while others are more complex.
One of the most common reasons for denial of insurance claims is a mix up in paperwork. Sometimes, your representative may inadvertently make a mistake in writing your name. An omission or alteration of a single letter of your name may suggest to the insurer that you are not one and the same person and provide a basis for denying your claim.
Secondly, where the insurance company does not consider the requested service necessary, it will not accept a claim based on the service. It may be that you do not really need the service or though you need it, you have not convinced your insurer, in which case, you will need to provide more information to demonstrate that you need the service.
Sometimes, your insurer may want you to try a less expensive service first. Here, the insurer will approve your request if you try the less expensive option and it fails to work. Similarly, the choice of service provider may determine whether your claim will be approved or denied. The insurer may decline your request for a service from a certain service provider but still be willing to accept a request for the same service but from a different service provider. Where applicable, you will have to convince your insurer that your choice of service provider is the only one capable of providing the particular service.
Failing to follow the rules is another common reason for denial of insurance claims. If you are insured without your insurer’s prior authority, the insurer may reject your claim even though you actually need their help.
How to Appeal Your Insurance Claim Denial
The denial of your insurance claim is not the end of everything. Here is what you can do to get it approved.
- Find out why your claim was denied. As pointed out above, there are many reasons that an insurance company can deny your claim. When you receive a denial, your first assignment should be to identify the particular reason why your claim has been denied. The denial letter should contain the reasons for the denial, if not, ask your insurer to give you written reasons for the denial- this will form a record and help you address the problem adequately.
Learn about the appeal process. This step is particularly necessary if you are not intending to enlist the services of a lawyer for the purposes of the appeal. Your insurer will usually have an internal appeals process. Make sure that you file your appeal within the stipulated timelines. If in doubt, call your insurer’s customer care and find out more information.
File your appeal with the necessary evidence. If your claim was denied for insufficient evidence, make sure you obtain all the requisite documents to support the appeal. Do not repeat the mistakes you made in the initial application. Remember that the insurance company will consider the merit of your claim based on the medical evidence you place before it.
What if the appeal is also denied?
Even when your appeal is denied, you can still pursue your claim by instituting a civil suit in court. Sometimes, depending on the reasons given for denial of your initial application, it may be appropriate to go to court directly without having to go through the internal appeals process. There is no law in Canada requiring you to exhaust internal appeals mechanisms fast before going to court. It is advisable to consult an insurance lawyer every time your claim is denied to get advice on whether you should appeal or go to court. The lawyer will also evaluate your case and tell you if you have a good case, and in many instances, the insurance company is wrong to deny a claim.