Insurance is not always as simple as other products, and insurers can refuse protection in many different cases. Can insurance companies deny coverage?

Under current law, health insurance companies cannot refuse to cover your insurance costs or charge you additional fees just because you have a “pre-existing condition” – that is, a health problem that you had prior to the date your new health began.

What does this mean for you?

Health insurers can no longer charge more or refuse to insure you or your child because of a pre-existing health condition such as asthma, diabetes or cancer. They may not limit the benefits of this condition. When you have insurance, they cannot refuse treatment for your previous condition.

In what cases, however, can they refuse?

Renewal of insurance coverage

The insurance company is not obliged to extend the insurance policy of any of the policyholders. If the policyholder has excessive claims or a change in circumstances that make him uninsured, the company may cancel the extension. In other cases, they may increase the premium to reflect increased risk.

Can insurance companies deny coverage?

Claims rejected

Even if you pay premiums regularly and on time, the insurance company may not pay your claims. First, the situation around the claim may not be covered by the policy because it is one of the exclusions listed. One example is when homeowners are flooding and claiming their insurance company. Since floods are not covered by home insurance but by flood insurance, these claims are likely to be rejected. Secondly, the claim can be nothing more than a deduction, which means that the insured is responsible for its payment. Finally, the insurance company may consider that the damage was caused by the insured, which may allow him to reject the claim.

What can you do if the payer refuses care?

If you have been denied payer insurance, don’t panic. Refusal does not mean that your payer will absolutely not cover the test or procedure. There are many nuances in medicine and no two people are the same. Sometimes the payer simply needs to be educated why a test or therapy will be most beneficial for a particular person.

Again, before calling, make sure that the treatment you want to include is not explicitly excluded from your plan. For example, even if you have an acceptable indication, insurers are unlikely to pay for medical marijuana. In this case, your insurance will not pay no matter what condition or symptoms you are dealing with.

If the payer refuses you, you can do several things: 

  1. Fight denial
  2. Ask your doctor what alternative may exist
  3. Pay in cash for the service
  4. Do not perform the test or treatment



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