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When can your health insurance refuse to pay for your care?

On Behalf of | Dec 27, 2021 | Bad Faith Denial Of Patient's Claim For Medical Insurance

Modern medicine can achieve incredible things, but it comes with a staggering price tag. The average working adult cannot afford to pay for emergency healthcare out of pocket. They rely almost exclusively on coverage by their insurance provider to pay for the care they need.

Whether you have cancer or get hurt in an accident and break a bone, you should be able to rely on your health insurance plan to cover the necessary treatment. Unfortunately, a for-profit insurance company has plenty of possible motives to refuse to pay a valid claim. When is it legal for your insurance company to refuse to cover your care?

When you have not met your deductible

In general, insurance companies impose patient responsibilities on their policyholders. Needing to pay a certain amount out-of-pocket to meet a deductible is a common requirement. No matter how much you need care, you will have to pay your deductible before the insurance company will cover any of your treatment costs.

When the policy documents exclude the treatment

Every insurance company has its own rules about what kind of treatment its different policies will cover and what kinds of treatment it will not. What treatments a particular plan will pay for depends in part on the success rate for the treatment and also how new it is.

Treatments with lower success rates or that are very new are less likely to have coverage under a standard health insurance plan than universally-acknowledged treatments used for years. Insurance companies often refuse to cover any sort of experimental treatment and will also refuse to pay for medications or drugs used contrary to their stated medical purpose or off-label.

Some denials may constitute bad faith insurance practices

Health insurance companies have to balance the treatment needed by their policyholders with overall plan administration expenses. Bad faith insurance practices put the profit of a company ahead of the needs of those who have paid for insurance coverage provided by that company.