Claim Denied

What can be more frustrating than getting denied health care coverage just when you really need it?

If you cannot get your claim paid then you bought insurance you did not need.

One attorney who deals with these issues, Mala M. Rafik of Rosenfeld & Rafik in Boston, says knowing the ropes is key. She handles cases of chronically ill patients in which health care costs can run some $200,000 annually.

Medical insurance denials, she says, most frequently come in these two areas that health insurance salesmen conspicuously omit when they sell your policies.

I will take exception to the comment “insurance salesmen conspicuously omit”. Of course there is a big difference in a salesman and a professional agent.

A salesman just wants your signature and your money.

A professional agent will take the time to find out what you really want, explain what you really need, and help you find the plan that suits both.

Insurer "caps" or limits. Most health insurance policies have annual spending limits on coverage such as skilled nursing care; durable medical equipment, such as wheelchairs and ventilators; and occupational therapy.

OK I may be making a step in the wrong direction, but it appears this comment refers to major medical policies. In that case the statement is true. There are policies that do cover these items but they are not major medical plans.

Services deemed "medically necessary." Want a private nurse to stay in your home to help you go to the bathroom after surgery? Your insurer may not consider this necessary and refuse to cover the cost.

Medical necessity is at the root of most health insurance policies. Again, there are ways to cover items such as private duty nursing with something other than a major medical policy.

When you purchase an insurance policy it is important that you actually READ your policy and make note of what is covered, what isn’t. In many cases you will want to consider purchasing insurance to cover some of the items listed above.