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91.5 percent of people in the United States have some form of health insurance, according to a 2018 census report.

Are you one of these people? If yes, you made a smart decision.

In a country where the cost of basic healthcare is sky-high, having health insurance coverage ensures you can access medical services whenever you need them. You won’t worry about settling your bill out of pocket.

Unfortunately, sometimes health insurance companies refuse to pay out claims. What should you do if you’re in this situation?

Here’s what to do when health insurance won’t pay.

Establish Why Your Coverage Provider Is Refusing to Pay

The time after a health insurance company refuses to pay your claim can be confusing. Infuriating even.

You always hold up your end of the deal by paying your monthly or annual premiums on time. When the time for the insurance company to hold up their end of the deal comes, you want them to settle the claim promptly. If you were admitted to hospital, for example, in many cases the facility will only discharge you after your insurance provider has acknowledged the claim.

It’s important to remain calm and composed after you learn that the insurance company won’t pay. Next, focus on establishing why the company is making that decision.   

Sometimes an insurance provider will reject a claim by mistake. Perhaps your healthcare provider made a clerical or billing mistake when filling out the claim. Or the insurance company’s claims processing employees denied your claim in error.

The insurance company will give you reason(s) why they denied the claim. If it stems from any of the above instances, a resolution will be made quickly.

However, there are also instances when an insurance company will have valid grounds to reject your claim. Maybe you sought treatment for a condition that’s not covered under the terms of your coverage. Or you visited a facility that isn’t in your insurance company’s network plan.

Regardless of the specific reasons for denial, know what it is will enable you to determine a suitable cause of action.

Paying Out of Pocket

It’s important to understand that health insurance isn’t a blanket cover that’ll take care of all your medical expenses. Every health insurance policy has terms and conditions that policyholders must follow. Taking up the policy essentially means you’re agreeing to abide by the policy’s terms and conditions.

As such, if your health insurance provider has a legitimate reason not to pay your claim, your best option is to settle the bill out of pocket. For example, if your policy has a waiting period for a certain health condition, say cancer, and you seek cancer treatment before this period lapses, it’s clear the insurer has sufficient grounds to reject the claim.

Paying out of pocket can take a big toll on your finances, but some facilities will allow you to work out a payment plan.

Appeal the Decision

A health insurer’s decision to deny a claim isn’t cast in stone.

When it rejects a claim, the company must tell the policyholder why it took the decision. It must also inform the client that they can appeal the decision if they wish.

Of course, if you believe the insurer has no grounds to deny you claim, the next step is to file an appeal.

Filing an appeal isn’t simply about pushing back the claim to the insurer. You might need to make some changes that address the reason the insurer gave.

For example, if the insurance company rejected your claim due to overbilling, you ought to ask your healthcare provider to review their billing and establish whether they made a mistake. If the billing is correct, ask the healthcare facility to provide additional evidence to back up the bill.

Insurance companies have internal departments that handle claim appeals. Your first appeal will go through the internal process.

However, there’s no guarantee the appeal will be successful. If your internal appeal is denied by your insurance company, Jeffrey Preszler of the Preszler Law Firm says that you might still be eligible to file an external appeal with the help of a lawyer.

Filing an External Appeal

Filing an external appeal is an ideal way to find redress if you still have reasons to believe your health insurer is acting unfairly. Note that the insurer will still give a reason why they denied your appeal.

The process of filing an external appeal varies from state to state. In most jurisdictions, however, there are government agencies or consumer protection departments that are in charge of these appeals. All you have to do is file an external appeal with the relevant authority in your state and furnish them with the relevant information.

If your external appeal is successful, your health insurer will have no choice but to settle the claim. If it’s denied, meaning that the insurer was right all along, you have to find a way to sort out your healthcare provider.

Reach Out to Medical Bill Assistance Organizations

Did you know medical bills are the leading cause of bankruptcy in the United States?

If your health insurer won’t pay and they have valid reasons not to, your medical bill will be on you. What if you’re unable to pay it out of pocket or your healthcare provider isn’t willing to negotiate on a flexible payment plan?

This is where medical bill assistance organizations come in.

These are usually charities that are dedicated to helping people like you settle their medical bills. Each charity will have its own criteria for choosing who to assist, so be sure to conduct enough research before reaching out.

Now You Know What to Do When Health Insurance Won’t Pay

Purchasing health insurance is a sound decision, both for your finances and health. As long as you keep the policy active, you will have coverage. However, there are instances when your health insurer can reject your claim.

With this guide, you now know what to do when health insurance won’t pay.

Keep reading our blog for more helpful advice and insights.

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