Limits of Health Insurance Coverage

Health insurance coverage for medical expenses is not unlimited. It may surprise you to find that your health insurance coverage has certain limits, exceptions, and benefit caps. The more you know about what your health insurance does and does not cover, the more you can protect yourself from unwelcome surprises when filing a claim.

Pre-Approval for Services

Before undergoing a major test or procedure that will cost a lot of money, many health insurance companies require pre-approval, also known as pre-authorization. This step ensures the service in question is medically necessary. However, pre-approval for a certain medical service is not the same as the approval of your health insurance claim.

Although most pre-authorized services are later approved for benefits, pre-approval does not guarantee that the health insurance company is going to cover the service. Whether or not an insurance company will pay for services depends on benefits eligibility and other factors. Your health insurance claim could still be denied even if you received a pre-approval for the service.

In-Network vs. Out-of-Network

Most health insurance plans are designed to cover services rendered by in-network caregivers and physicians. In-network providers are those with existing contracts with the insurance company. You can typically find a list of in-network healthcare providers through your health insurance company’s website or by calling your agent.

Typically, if you choose to receive care from a provider who is out-of-network, you will pay more money in fees and deductibles. Your company may not cover an out-of-network provider or may only offer partial benefits. Do your best to find an in-network provider. Even then, double-check to make sure the services rendered are covered under your policy. Make sure any medical tests are sent to an in-network lab, as well.

Prescription Drug Costs

Most health insurance policies cover all or most of the out-of-pocket costs of prescription drugs. There are some limitations, however, on what a health insurance provider will pay for off-label uses of a drug. If, for example, your doctor prescribes a drug for your condition that has been tested and approved for a different disorder, the insurance company may reject coverage if your condition is not listed on the label.

You may also encounter limits on your health insurance coverage if your claim involves a broken law. If you were driving drunk, for example, an illegal act health-care exclusion may bar you from coverage. An illegal act exclusion could also affect your ability to obtain benefits for a prescription for medical marijuana, as the insurer may debate its legality. Although medical marijuana is legal in Arizona, it is still prohibited by federal law.

Appealing a Denial

If your health insurance company denied coverage for a medical service, you can appeal the denial. The first step is understanding the reason for the denial. Read the denial letter and carefully review the language of your health insurance policy. Then, request an internal review of the denial from the insurance provider.

Your health insurance company will assign someone to review your claim and decide whether or not the denial is valid. If an internal review does not lead to the approval of your claim, you can appeal the decision by requesting a review by a third party (external review). With an external review, the decision to deny coverage will no longer rest with the insurance company.

Was Your Claim Wrongfully Denied or Underpaid?

If you believe your health insurance provider wrongfully denied or underpaid your claim, contact an insurance bad-faith attorney in Arizona for legal assistance. A lawyer can review the facts of your case, help you comprehend the terms and provisions of your health insurance policy, and represent you during negotiations with a health insurance corporation. An attorney can help you fight for the insurance benefits and case outcome you need deserve.