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The Secrets of Health Insurance Companies


Health insurance companies are supposed to protect their policyholders by providing financial protection and reimbursement against losses. They collect premiums from their clients over a period of time to pay for future losses. When a person buys an insurance policy, they are entering into a contract. This contract is expected to be upheld and followed even when unexpected accidents and expenses occur. There are laws set in place to help and protect policyholders from health insurance companies when they wrongfully deny coverage to their insured. Read on to find out how you can identify the signs of wrongful treatment and how to protect yourself.

What Should Health Insurance Companies Cover

This list does not include all the possible items and instances of coverage. To see a full list of items that should be covered by your insurance company, take a further look into the details of your health insurance policy. The list below includes major services that should be covered under basic policies:

  • Must adhere to the Affordable Care Act
  • Must follow individual state laws
  • Outpatient care (Ambulatory patient services), which includes doctor visits, X-rays, etc.
  • Prescription drugs
  • Pediatric services
  • Preventive care, which includes regular checkups, health screenings, etc.
  • Laboratory services, such as pathology, blood work, organ function, diagnostic tests, etc.
  • Emergency services
  • Hospitalization for surgery, overnight stays, and other conditions
  • Birth control
  • Breastfeeding
  • Mental health and behavioral coverage, such as seeing a psychologist, therapists, receiving treatment, etc.
  • Substance use disorder services
  • Rehabilitative and habilitative services, which includes physical therapy, occupational therapy, treatment, medical equipment, etc.
  • Pregnancy, maternity, and newborn care

Ways Health Insurance Companies Will Deny Policyholders

There are many possible ways for health insurance companies to deny coverage and put you in an unpleasant situation. Below are signs to look for to help determine if you have been wrongfully treated:

  • Claim is denied with no explanation
  • Delay in handling of a claim
  • Not conducting a thorough investigation
  • Claiming there is no coverage under the policy without proof
  • An unreasonable settlement or payout is offered
  • Falsely marketing their insurance plans and coverage
  • Attempting to mislead, misrepresent, and deceive
  • Failure to notify policyholders in the event of a change, including but not limited to their provider network, coverage, policies, etc.
  • Failure to disclose to potential policyholders’ important information about current and pending changes
  • Making the claim process difficult by asking for additional documentation and actions

What To Do if This Happens to You

If you believe you have suffered from a health insurance company wrongfully denying coverage of your claim, help mitigate your losses and continue with the steps below.

  • Contact the insurance company and determine their reason for denial.
  • Reread your policy to verify whether their denial reasoning is legitimate.
  • If you are unable to resolve the denial at this point, you have the right to reach out to an experienced health insurance attorney for advice and to help you appeal the denial.
  • Do not give up. Be persistent and follow through.

Every case is different and depends on the information present, the policies set in place, and the actions of both parties. Not every policy and situation are the same.

Our insurance attorneys at Mehr Fairbanks Trial Lawyers are experienced in working to get what you deserve. We believe no one should suffer as a result of unfair claims practices. Our mission is to get you the benefits you deserve under your policy. Give us a call at 800-249-3731 for more information and a FREE case evaluation. Let us fight for your rights and benefits while you focus on yourself.

“Legal to Us, Success for You”

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This information should not be construed as legal advice or a guideline to your specific claim.

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