A denial from a health insurance company does not always mean you cannot get coverage. Whether the denial is for enrollment in a health plan or for a requested service through your current insurer, there are options, such as appeals and government-sponsored health plans. When you receive a denial, ensure that you fully understand the reason for the denial. Do not hesitate to call the health insurer for a thorough explanation. This information will help you take the next step in searching for coverage.
Appeal the Denial
When a particular health care service is denied, you have the right to appeal the denial for reconsideration. Upon denial, your health insurance company will send an explanation of benefits stating the denial reasons. Gather supporting documents, such as medical records, letters from your doctors and correspondence with the insurer, to show why you should receive coverage. Call or write your health plan to file a formal appeal. You may have several opportunities, or levels, of appeal for the same denial. The health plan will make a decision to uphold the original determination or overturn the denial to allow coverage.
Obtain High-risk Coverage
When you are denied enrollment into a health insurance plan due to pre-existing conditions, find out if your state has a high-risk health plan. Per the Affordable Care Act, passed in 2010, coverage is available to anyone receiving a denial due to pre-existing conditions. Visit Healthcare.gov or your state's insurance department's website to see if your state has a high-risk plan. If not, you will have the opportunity to receive coverage under a federally-managed plan.
Apply with Multiple Insurers
Just because you've been denied coverage by one private individual health insurer does not mean all of them will deny you. Meet with an insurance agent to help find your coverage options or go to a website, such as eHealthInsurance.com, to obtain multiple quotes. Apply with national insurers, such as United Healthcare, Aetna and Cigna. Also apply to your regional Blue Cross/Blue Shield and insurers, such as Assurant, that may offer riders to cover specific conditions.
Bottom Line
The bottom line about a health coverage denial is that you have options. No one should be without insurance. If your current insurer denies a particular service, appeal the decision until you have exhausted all levels of appeal. If you can't get coverage through private insurers, contact your state's insurance department for assistance in finding a plan that will accept you.
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