What are some common rules that insurance companies often violate?

Insurance denials and their reasons often violate contractual rules. While almost every patient will experience a run in with an insurance company, there are two rules of most insurance contracts that are most often violated.

Reimbursement Claims

Your insurance contract says that you can send in receipts for reimbursement for medical expenses paid for out of pocket; you do so and weeks later receive a letter saying that the amount you sought is either 1) unqualified for reimbursement or 2) added to your deductible. In this situation, to avoid having to pay out money, the insurance company will ignore your reimbursement request and do what they see fit to do, regardless of how tenuous the basis for their action.

Reduction of Expenses

Another common type of rule breaking is when insurance companies refuse to pay for the total amount of out-of-pocket expenses. Insurance companies negotiate reduced rates for medical treatments; medical treatments paid for out of pocket are more expensive. To avoid needing to pay you for your reimbursement claim, an insurance company might refuse to pay you anything more than what they would owe under the reduced rate.

Prior Condition Denials

Most insurance companies refuse to cover pre-existing conditions when they take on a new customer. In fact, most companies require 30-60 days to pass before they will provide any medical coverage. Unfortunately, even after the passage of the required time period, is it not unusual for an insurance company to deny coverage based on a pre-existing condition. At the very least, companies would require extensive documentation that the condition was not present prior to the beginning of coverage which would delay payment.

If you believe that your insurance company has broken one or more rules of your insurance contract, talk to an attorney. A lawyer will review your contract and your allegations and discuss with you whether you have a cause of action for breach of contract against the company.