The Insurance Representative Says the Treatment is Covered.  But is It?

During an office visit with your doctor, she recommends you undergo a treatment you’ve never had before. You call your health insurance company, and a representative assures you the treatment is covered by your health insurance plan. Can you rely on what the representative says? Will the treatment be covered by your insurance?

Caution is Key

Be cautious when relying on what health insurance representatives tell you over the phone. The representative can give you general information about what services are covered by your health insurance, but she cannot guarantee that you have met all the requirements under the terms of your policy for the treatment to be covered for you.

For example, all health insurance policies only cover treatment that is medically necessary – meaning the treatment is considered appropriate by the medical community to treat the illness or condition being targeted by the treatment. Representatives will rarely tell an individual over the phone if a treatment is medical necessary, even though this is always a prerequisite to a claim being paid by the insurer. Also, some treatments may be covered if they are used to treat one illness but be considered experimental when treating a different illness. Because the representative may or may not know the medical condition for which you are receiving the treatment, she may not warn you about this potential problem. Other exclusions may also apply based on your diagnosis or your treatment history.  The representative may not tell you about possible exclusions or limitations; he does not generally have access to that private medical information.

Please Read Your Policy

It’s best to read your health insurance policy along with any summary documents explaining your coverage and determine yourself whether the treatment your doctor recommends is covered.

If you have a health insurance claim that is denied, contact Kantor & Kantor, LLP and have an attorney review your case to see if you can challenge the denial of the claim. We can be reached at (818) 886-2525 or via our online contact form. You don’t pay unless we win your claim, so you have nothing to lose!

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