When Health Insurance Doesn’t Cover Your Medical Care

While it’s true that the costs for health insurance coverage continue to increase, having a health insurance plan will save you more money in the long run. But no health insurance plan will cover every medical treatment an insured individual needs over the course of his or her coverage period. No matter how good your health insurance is, you may occasionally encounter a medical treatment or condition that is not covered by your health insurance policy. Although these situations are normally confined to elective treatments like cosmetic surgery and liposuction, that is not always the case.

If you are in need of a non-elective treatment that your insurance company is unwilling to cover, and it is not specifically listed on the “excluded treatments” section of your health insurance policy, ask your insurance company for a written explanation of their reasons for issuing such a denial. Then show this to your physician. Many times, simply re-coding a procedure or treatment and re-presenting it to your insurance company are all that’s needed to get approval for the treatment.

But what happens when the procedure hasn’t been miscoded or can’t be re-coded and coverage for a medical treatment you already received has been denied by your insurance agency? The hard truth is that by this point in the process, you do not have many options, and you may end up being responsible for paying the full cost out of your own pocket.

One option you do have is the opportunity to appeal a decision if you do not agree with it. Every insurance company has a process to go through to appeal a claim, and you need to follow the steps involved in the appeals process precisely. Insurance companies would rather throw your appeal out on a technicality than invest the resources necessary to investigate the claim. The appeal process is typically outlined in your policy handbook. You can also discuss the situation over with your medical care provider before proceeding with the appeal to get another point of view or advice on how to proceed.

If, despite your best efforts, the treatment still is denied, all is not lost. Here are some other options that are worth pursuing that may help you avoid paying full price:

1. See if your doctor will negotiate a lower payment or authorize a payment plan.

2. See if your doctor is a member of a medical discount program that you can join. There are thousands of doctors who participate in these networks.

3. If you’ve not yet had the procedure, shop around for another doctor who is willing to do the procedure for a lower price.

4. See if you qualify for free treatment at a public hospital or clinic because of your income level, veteran’s status, or some other socio-economic reason.

With a bit of persistence and some extra effort, it is very likely that you’ll end up with the treatment that you need at a price you can afford.

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