Question

What is your recourse if your health care is denied? Why might the denial have been issued? Has this ever happened to you? If so, what did you do?

Please provide one reference source in APA 6 format

Answer 1

When there are small issues that can be resolved through the phone then there is no problem. But, for issues that need more than a phone call to resolve things, the only recourse would be profit or non profit entities that offer advice for the course of action. You will need to get complete details regarding you plan to go ahead.

It is very important for one to understand why the claim was denied. Then check if the reason was a minor error and if there is a possibility for the claim to be resubmitted. Collect all the evidence necessary to help support your plan of recourse. Submit the same to the insurance company. Follow up with the proceeding of your claim with the insurance company, a gentle reminder always helps. If the claim is denied again, take the help of law ( many states have consumer advocates that help with health insurance).

POSSIBLE REASONS FOR DENIAL:

• For government sponsered plans, when the annual income of a family is above a certain level ( this again varies on number of children in the family) they could be denied claim.
• If insurance company feels the medical procedure is not necessary.
• When there is lack of payment towards the insurance plan.
• When some information is missing or is wrongly entered.
• When claim is submitted more than one time for the same service.
• When last date for applying for insurance claim has expired.There is a set number of days from the day service has been delivered. The time or number of days includes a time period to work out any possible rejections/ denials. If, this period also lapses, then there could be a denial possible.
• When the same service can be claimed from your spouses insurance plan ( In case of government subsidised plans).
• When the person works in an environment that could be dangerous. For example, firefighters or the police.

Denial of medical claim has never happened with me.