It is an unfortunate reality that, when filing a benefits claim, you might end up receiving a denial letter. This can be frustrating – particularly if you were counting on that coverage to come through. Any plan covered by the federal law known as ERISA will at least give you a chance to appeal the decision.
The first step to moving toward a solution is understanding why a plan manager or administrator might deny a claim. Here are three common reasons.
A lack of understanding
In some cases, an insurance company simply won’t believe you qualify. They might not see a health condition as truly serious, for example, or may determine you can still work a comparable job. It’s also possible your claim simply didn’t have medical documentation that accurately explains what you’re dealing with.
What this usually boils down to is a lack of understanding about how your circumstances are affecting your life.
Filing a claim means gathering and filling out a lot of paperwork. It’s not uncommon for a claimant to make a small mistake – a missing piece of information, an incorrect address, maybe a lapsed deadline. These small missteps, however, can result in a denied claim.
Benefits plans have restrictions. It’s possible a filed claim simply falls outside of the plan’s limits. That might be because the plan does not cover a specific condition or circumstance. It’s also possible you’ve reached the maximum amount of treatment the plan allows for.
The good news: You can address these problems
When insurance denies a claim, ERISA requires them to explain why. Not only does the denial letter need to include the reasoning for the decision, it must also point to the part of the benefits policy that supports the rejection.
This allows you to rebuke these issues directly. If the denial letter says there wasn’t enough medical evidence, for example, you can gather additional medical evidence before filing an appeal (a process you should strongly considering hiring an ERISA attorney to help with). A denial letter also has to specify which additional materials are needed if the rejection was due to a lack of information.
ERISA claims appeals can be complex, often requiring assistance from a lawyer to successfully win. Knowing beforehand what you might be facing – and how to respond – can offer a path forward.