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Dealing With Insurance Denials


If you are injured or sick, the last thing you want to do is arm wrestle with an insurance company about your claims. These companies have a staff of people on hand whose job it is to achieve the best outcomes for the insurance company, not you. If you find yourself wrangling for payments that you legitimately deserve, getting a good insurance attorney on your side can make all the difference.

Reasons Given for Denials

When they deny your claim, insurance companies are required to explain the reasoning behind the denial, which comes in the form of an explanation of benefits (EOB). This form will often be written in insurance lingo, with multiple codes or abbreviations that are difficult to decipher. Reading the EOB may leave you feeling more confused than you were when you started. Speaking to an actual customer service representative is a good first step to figuring out what’s behind the denial of your claim. Some of the most common reasons for denials include:

  • Charges for service or condition that is not covered by your policy: Sometimes you may believe you have coverage, only to discover that your policy excludes certain procedures.
  • You failed to obtain pre-authorization: Often, procedures require pre-authorization by the insurance company as a prerequisite to payment. MRIs and CT scans are just a couple of tests for which many companies insist on preauthorization.
  • Using a provider outside the network: If you choose to see a doctor who has not contracted with your insurance company for a non-emergency, you may be stuck with the bill.
  • Typos cause confusion: If you can’t seem to get to the bottom of the problem, take a good look at the documentation of your claim. Simple errors in the spelling of your name, in transposed numbers, or other similar errors can put your claim in jeopardy.
  • The medical provider billed the wrong insurance company: You may have neglected to update your insurance information after switching jobs.
  • There is confusion regarding which of two policies is primary: If you and your spouse each have coverage, there may be questions as to which policy is responsible for initial coverage.

Preventing and/or Responding to Insurance Denials

Insurance experts have several tips as to how to deal with insurance companies whose response to your illness or accident disappoints:

  • Read your policy and understand its provisions;
  • Discuss your concerns with your documentation in hand so you give accurate information;
  • Schedule those discussions quickly after receiving notification of a denial;
  • If you feel you have a legitimate concern, don’t give up;
  • Appeal the decision in writing, giving precise and detailed information backing up your stance;
  • In your appeal, include copies of medical documentation to support your claim.

Let Us Help You Today 

If all of this seems overwhelming, don’t despair. Certainly, medical issues may interfere with your ability to go to battle, but with the experienced team at the Law Offices of Robert W. Elton on your side, much of the manpower and stress may be lifted from your shoulders. If your insurance dispute is overwhelming you, give us a call in Daytona & Ormond Beach. The initial consultation is cost-free.