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What are typical problems that arise in getting health care benefits provided or paid?

UPDATED: June 19, 2018

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Coverage and benefit disputes in health care insurance and health care service plans that frequently arise include the following:

(1) The insurer or plan contends that care was not "medically necessary," which is often defined as care which is reasonably required according to accepted norms within the medical community.

(2) The insurer or plan contends that the charges were not "usual, customary and reasonable" for the services rendered.

(3) The insurer or plan contends that the treatment was "experimental" or "investigational," which generally means that the care has not been accepted in the medical community as normal treatment or treatment that has not been proven to be effective medically.

(4) The insurer or plan contends that medical care was received outside a specified geographical service area and was not emergency care.

(5) The insurer or plan contends, with respect to extended care especially, that the care constituted "custodial care" or "long-term rehabilitation" which are usually excluded from coverage. This issue often arises in the context of persons confined to skilled nursing facilities or persons requiring home health care.

Check here for a helpful article on dealing with insurance companies when you have a high risk illness.

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