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What to do when your insurer refuses to pay

On Behalf of | Nov 10, 2022 | ERISA

Insurance companies in New Jersey are not always as willing to provide coverage as you may feel they’ve led you to believe. Your claim might be a minor incident or a significant medical situation requiring extensive care. No matter the type of claim, it’s never a pleasant situation when your provider won’t shill out and provide you the coverage you thought they would.

What happens when insurance won’t pay?

Sometimes, the provider will refuse to pay the entire claim. Other times, they will only deny part of your request. In both cases, there are actions you can take to get the expenses covered. A helpful place to start is the reason why the insurance company denied a payer’s request for coverage to begin with.

If your ERISA claim is denied after receiving medical service, the first thing to do is carefully review your plan’s coverage. This will allow you to determine if the insurer’s denial of the claim was legitimate or not.

What makes a legitimate claim denial?

Look closely at the specific clauses that come into play. Try to see how the insurance company may have interpreted the clause. You can then use that to determine how you can argue against that interpretation.

It’s crucial that you have a comprehensive understanding of what your plan does and does not cover. Make sure to review the details of your plan ahead of time so you know for certain that your claim is legitimate. This may prevent you from devoting a significant amount of time and energy to reverse a claim denial that was actually legitimate.

There are times when your insurance company won’t be as eager to cover a medical expense as you’d like them to be. Don’t be afraid to use your own common sense. If it seems to you that a claim denial was unfair, you might be right, and it may be worth pursuing.