What are some common reasons why a health insurance claim wouldn't be paid?
The most common reasons for delayed payment of health insurance claims or claims not being paid include:
Improper documentation/lack of receipts: Submitting claims without copies of the original receipts will likely result in claim rejection.
Costs submitted after 12 months: Claims must be submitted within 12 months of the date you paid for the expenses you're claiming.
Costs that aren't medically necessary: Generally, health claims must be deemed medically necessary under the terms of your plan. Preventative dental services aren’t usually medically necessary; however, they may be allowable if your plan covers them.
Excluded conditions: Some plans (Medically Underwritten) require insured persons to qualify medically, which involves the completion of a medical questionnaire. Consequently, specific health conditions may be excluded from these plans. When a medical condition is excluded, it means there is no coverage for any treatments—including medications—related to the excluded condition. If a treatment normally used for an excluded condition is being used to treat an unrelated condition, your health provider must provide a written explanation. Include this explanation when you submit your claim.
Improper documentation/lack of receipts: Submitting claims without copies of the original receipts will likely result in claim rejection.
Costs submitted after 12 months: Claims must be submitted within 12 months of the date you paid for the expenses you're claiming.
Costs that aren't medically necessary: Generally, health claims must be deemed medically necessary under the terms of your plan. Preventative dental services aren’t usually medically necessary; however, they may be allowable if your plan covers them.
Excluded conditions: Some plans (Medically Underwritten) require insured persons to qualify medically, which involves the completion of a medical questionnaire. Consequently, specific health conditions may be excluded from these plans. When a medical condition is excluded, it means there is no coverage for any treatments—including medications—related to the excluded condition. If a treatment normally used for an excluded condition is being used to treat an unrelated condition, your health provider must provide a written explanation. Include this explanation when you submit your claim.