Health insurance is one of the major insurance products. With the cost of health care constantly on the rise, health insurance can cushion you from out of pocket expenses. There are times when an insurer may pursue a denial of claim. Some of the legal reasons for a health insurance denial include:

Pre-existing condition

A health insurance claim denial may occur when the insurer finds out that the condition, for which you are claiming, has already existed before the policy commenced. The claim will be denied if the policy has a pre-existing condition clause. Claims for other unrelated illnesses that were not pre-existing, may also be denied if you failed to disclose a pre-existing condition when applying for the policy.

Lack of medical necessity

The insurer may question procedures that are not medically necessary, and the physician may be required to show why a procedure had to be done. Claims for procedures that have no sufficient reason for being carried out may be denied. On the other hand, routine procedures are not usually questioned.

Exhaustion or exclusion of benefits

Most insurers have a list of procedures that are not covered by their policies. Some of these procedures are methadone treatment, gastric bypass treatment, experimental surgery, infertility treatment and cosmetic surgery. Also, if your claim exceeds the benefit limitation, it may be denied. For example, if your health insurance covers only 30 days of hospitalization treatment for substance abuse or behavioral problems, and your stay exceeds this, there may be a denial of claim.

Pre-authorization was not obtained

Most insurers require you to obtain pre-authorization for a variety of non-routine treatments. These include mental health care, substance abuse care, surgery and hospitalization. There may be a health insurance denial, should the patient fail to obtain pre-authorization when he commenced the treatment.

Incorrect coding or paperwork filling

Some insurance companies will delay or deny a claim, if the paperwork was improperly filled. Also, if the coding was improperly done, the insurer may deny the claim. Fortunately, having the paperwork filled correctly, and asking your doctor to secure proper coding can resolve these issues.

Lack of progress

If you condition requires you to receive long-term medical care than was anticipated, you may be denied claims. This is also the case if you have been on long term medical care, but your condition does not seem to improve. The denial may not be explicitly stated. It may be inferred through words like "no restorative potential, "chronic", and "stable".

Other reasons that can lead to a health insurance claims denial may be outlined in the standard health policies. You simply have to check the section on claim denials to be full prepared.