Insurance companies receive money from their policy holders, so that those same policy holders can seek the promised benefits, if any one of them should sustain a severe injury. Some insurance companies promise to cover the expenses associated with a long-term disability. Unfortunately, some of those same companies refuse delivery of the expected payments after 2 years of coverage.
Perhaps you know the feeling that overtakes someone that has received a denial letter. Maybe you have been denied benefits by an insurer. You understand how it feels to get deprived of a benefit that you have paid for. Well, you should not feel that you must accept the insurer’s decision and let your personal injury lawyer in Corner Brook help you.
What is behind that decision?
There is no one answer to that question. Insurers have a number of different reasons for sending out denial letters. Sometimes an automatic process leads to the issuing of such a letter.
Action to be taken by the person that has been denied a claim to insurance benefits:
Try to learn the reason for the denial. You may have made a mistake on the claim form. Perhaps you entered the wrong information, referred to the wrong billing code, or failed to include all of the required documents. If you were denied your claimed benefits due to commission of such an error, then you have the right to submit a corrected claim form.
You can appeal your denial, if the insurer’s decision was based on a mistake that copies one of those on the following list:
• The submitted claim form must be accompanied by a referral.
• The submitted form did not arrive before the stated deadline.
• You requested a service that is not listed in your plan.
• You requested a service that is not medically necessary, or one that is at a higher level than necessary.
• You requested a service that would need to come from an out-of-network provider.
• You submitted a claim for a treatment or diagnostic procedure that is experimental or investigational in nature.
• Your request exceeds the limits on your plan.
Facts to keep in mind when making an appeal:
You have the right to submit an external appeal, if you were denied because what you requested is not medically necessary, or if what you requested is experimental or investigational in nature. If you were denied for a different reason, you will have to initiate an internal appeal.
Study your plan before initiating an appeal. When you are ready to appeal the denial, collect the relevant medical records. Plan to include those in your response to the denial letter. That will show the insurance company that you can count on receiving medical support for the claims brought forward during the appeal process.