How can I avoid my health insurance claim from being denied?

UPDATED: Jul 27, 2010

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UPDATED: Jul 27, 2010Fact Checked

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Asked July 27, 2010

1 Answer


Read your policy carefully. Make sure that it includes everything you can anticipate. If you are already undergoing treatment, make sure that your preferred physicians are signed up in your health insurance network, or encourage them to join. Perhaps most important of all, make sure to follow the chain of command, with your primary physician referring you to the specialist you will need.

One of the key reasons for a health insurance claim denial is failure to stay within the network, or to seek the advice of your primary physician, sometimes called the gatekeeper. This person's function is to expedite your care by maintaining a central database of the specialists you are seeing and the treatments being undertaken. If you are not happy with the specialist you have been sent to, you can request a different one, or opt to use one from the list of approved member specialists in your health care network.

Be careful about seeking care outside of the network. You may not be covered for any of the costs associated with such medical care unless you have received prior authorization. If the preferred physician is not a member of the network, ask them to apply. Knowing that a doctor-patient relationship could be at stake, many doctors will agree to join, and your insurance company will be happy to forward an application to them at your request.

If you feel like you are being denied a claim unfairly, there are advocate health groups available where you can investigate other courses of action. Additionally, each state has a department or bureau devoted to overseeing insurance companies in that state, and they may be able to help you resolve your problem.

Answered July 27, 2010 by Anonymous

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