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Health Insurance Denials Based on Medical Policy Guidelines - The MFP Perspective

Most health insurance plans cover medical expenses if the treatment is medically necessary and not “experimental” or “investigational.” But the health insurance policy documents rarely spell out exactly what treatments the insurer considers experimental or investigational. Instead, health insurance companies will create separate “medical policy guidelines” that their claim examiners will use to approve or deny claims. These medical policies can result in a large number of claim denials if the insurance company has put in place a policy that denies all requests for a certain type of treatment.


If you get your health insurance coverage through your employer (or a family member’s employer), your insurance is likely subject to the Employee Retirement Income Security Act (ERISA). ERISA is a federal law that provides claimants and beneficiaries with a civil enforcement scheme to remedy wrongful denials of coverage.


Under ERISA, a claimant can file a lawsuit to enforce and/or clarify his rights to the benefits at issue. ERISA also allows a claimant to seek declaratory or injunctive relief if a particular medical policy is not consistent with current medical standards. In other words, if a medical policy is faulty and not based on prevailing medical standards, a claimant can ask a court to require the insurer to reprocess a claim using a corrected medical policy. This type of claim reprocessing is a common remedy under ERISA, and courts have the authority to order claim administrators to reprocess claims.


Many health insurers will apply their “medical policies” uniformly to all requests for coverage across their enterprises. This means that even if your doctor verifies your treatment is medically necessary and not experimental or investigational, the insurance company may still deny your claim because its medical policy says the treatment is always experimental or investigational.


If you have had a health insurance claim denied because your insurance company claims the procedure is experimental or investigational based on one of its medical policy guidelines, contact us for a free consultation to discuss your claim. Mehr, Fairbanks & Peterson is a leading legal interpretive authority on health insurance policy in Kentucky. We love helping you receive the care you deserve at a fair price.


Philip G. Fairbanks, Esq.

Edited by Iain Feeney

Mehr, Fairbanks & Peterson

17 June 2021