About Health Insurance Claims

There are many different health insurance policies available for purchase today and your insurance provider has a variety of ways to deny your claims.

A health insurance claim denial can come simply from a clerical mistake. Many different circumstances may lead your provider in which your insurance provider can find a possible cause for denial.


Understanding Benefits

Do you ever have difficulty understanding the patient financial responsibility? Have you ever had trouble figuring out what applies to your annual out-of-pocket maximum? Have you ever asked yourself what is a deductible? What is a co-pay? What is the difference between in and out of network? Many policyholders do not fully understand their policies. Merlin Law Group can assist.


Health Insurance Denials

Health insurance companies typically deny claims for a number of reasons:

  • Surgery is typically expensive and a topic of great importance. Whether or not your health insurance contract requires pre-approval, taking this extra step is strongly advised. Most health insurance policies will state in fine print that a pre-approval does not constitute a coverage decision. These extra steps can be an asset for the policyholder if the insurance company denies a claim for surgery.
  • Health insurance companies can be more concerned with profit and the bottom line than patients. Surgery claims are often denied on medical necessity grounds. The insurance company will often have an in-house physician who did not meet you before, during, or after the surgery, and who may state there was another option. Merlin Law Group can help you with these obstacles.
  • Health insurance companies arguing for a generic prescription even though the policyholder’s medical provider or pharmacy advises a name brand.
  • The complexity in the medical prescriptions.
  • The use of insurance companies to use a “waiting period provision” which many policyholders do not understand and sometimes can be used when denying your coverage.

Need More Information?

If your health insurance claim has been denied, delayed or underpaid, contact Merlin Law Group today for a free consultation.

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