Insurance claims are often denied because treatment didn’t fall under a policy’s definition of “medically necessary.” Click here to learn why.

Understanding the Term “Medically Necessary” When Pursuing an Insurance Dispute

When you see a doctor for treatment of injuries you sustained in an accident, you are focused on relieving the pain and treating the problem. You don't even think about whether the treatment he suggests follows the strict guidelines of your particular insurance coverage. And why would you? When it comes to treatment, you trust that your doctor is prescribing the best care he can for your situation. However, although you may have faith that your doctor is looking out for you, the same can't be said for your insurance company.

Insurance companies place their profits above your care. As a result, they have no problem denying simple claims based upon their determination of how necessary the treatment is for your injury. In order to satisfy their provisions, you must understand the difference between medically necessary treatment and elective medical treatment.

What Does Medically Necessary Mean?

The term “medically necessary” is defined as any services, treatment, or use of healthcare supplies that meet accepted standards of medicine which are needed to prevent, diagnose, or care for an illness or injury. Unfortunately, this definition is subjective to insurance companies, as they often argue that certain treatments may not be necessary. An insurer can use the term to deny legitimate claims for treatment that a doctor determined to be very much needed.

Common Insurance Disputes Involving Medical Necessity            

To understand and follow your specific insurance company’s regulations when it comes to medically necessary treatments, you must read your policy’s clauses regarding treatment coverage. Most health plans post their policies online. Therefore, to read your coverage, all you have to do is search for “medical policies” or “clinical policies” on your insurance company’s website.

These clauses outline how your insurance company decides whether specific treatments have been proven to be effective for your condition, and if so, whether they’ll be considered for coverage. Although these guidelines are mandated, insurance companies still have the freedom to interpret them as they see fit. Therefore, a claim can be denied if the wording fails to directly correlate with the policy’s guidelines. In these situations, you may be able to resubmit your claim if your doctor can reword the request more precisely to fit your insurance company’s requirements.

Insurance coverage can vary widely depending on providers, and even people with broad coverage may not fully understand the limits of their insurance policies. As a result, most will not discover that their insurance coverage will not cover certain services until after they have already received treatment, leaving them stuck with a high bill. If you are having difficulty with an insurance dispute, contact us today to schedule an appointment with an experienced attorney.