Why would an injury claim be denied by my health insurance?



One horrible thing to experience is getting in a car accident, being seriously injured, and finding out your health insurance won't cover car accidents.

In most cases, insurances provide harmony and comfort to people who purchase coverage for themselves and their property. However, as in the case above, to ensure one is getting the coverage they believe they have, the insured party must follow any restrictions, fine prints, and other additional agreements to be in full compliance.

Unfortunately, many don't pay attention to these fine prints and restrictions. As a result, they grow stressed and frustrated with their health insurance policy instead of experiencing peace of mind.

With a better understanding of how and why your health insurance can deny an injury claim, you can avoid the stress of your insurance provider denying any of your claims.


#1. There is a Waiting Period

The majority of health insurance plans have a waiting period requirement. During that period, certain predetermined illnesses or treatments are not covered. So if you file an insurance claim for anything that is not covered during this waiting period, your claim will be denied.

Unless you have supplemental insurance that does not have a waiting period, you can be stuck covering the entire bill by yourself if you have an incident during this period. 

FDNY Ambulance

#2. Your Information was Inaccurate

If the information provided on your claim does not match the information that your insurance provider has, they will decline it. Insurance companies do not want to waste money covering a bill for someone not covered under them.

It should also be noted that intentionally withholding crucial information to your health insurance provider can result in an immediate denial. It can even lead to more severe consequences, like legal matters, which could be considered insurance fraud.

When your claim is denied because of inaccurate information, in most cases, you can re-submit the claim with the accurate data. So you should not get too worried about a claim denial due to these circumstances.

#3. There is a Policy Exclusion

One thing that many might not know about ambulance rides is the fact that certain ambulance providers may not be covered under their specific insurance plan. This would be considered a policy exclusion. Not only can specific treatment be excluded, but certain injuries and illnesses can be excluded from a policy's coverage.

This is another example of why people should always read every word on their insurance policy. The worst thing is to have a denial because of a technicality and tricky wording within a policy. It is best practice always to know what you are signing up for before committing.

#4. Expired Coverage or Lapse of Coverage

This may seem like an apparent reason to have a claim denied, but it is an example that happens more often than people think. Suppose you forget or avoid renewing your insurance, which causes it to lapse. In that case, your doctor's visit or injury may not be covered if it happened in between coverage.

For situations like this, people are most likely out of luck. Due to you not having any coverage during the injury, you will be stuck paying cash for your treatment. The only exception is if you have additional insurance coverage outside of that one provider.

#5. There was a Delay in Treatment

Say you were injured in a car accident or some other accident, and you waited to seek treatment because your work situation did not allow time off. When you were finally able to get the treatment, your insurance provider denied your claim because you didn't make an immediate complaint or didn't seek immediate treatment.

This would more than likely leave you feeling frustrated and financially lost. To avoid this happening, be sure you refresh your memory on treatment timelines and how long you have to seek treatment before agreeing to a policy. 


#6. There was a Lack of Medical Records

If there are no medical records to prove that an injury occurred, then your claim will probably be declined. Doctors' offices will usually send claims directly to your insurance company with medical records as supplemental documents.

This is typically something you should not have to worry about. Still, you should immediately reach out to your doctor's office for the respective medical records if you do.

#7. Failure to Avoid or Mitigate Injury

When an accident happens, insurance providers ask many questions to have a broad understanding of the situation that resulted in the injury. If the representative investigating your claim decides the injury could have been avoided, they can decline your claim.

For example, if you are injured because you merely avoided doing functional exercises that help improve your strength, your claim can be denied. Putting yourself in a position to be injured can not only lead to a denied claim but can result in your policy being canceled because of breaching the agreement.  

#8. You Have a Preexisting Injury

Another one of the ways your claim can be denied is by having a preexisting condition before the incident that caused the "injury" occurred. For example, if I had a dislocated shoulder the day before getting into a car accident and then claimed the dislocated shoulder resulted from the accident, I can receive a claim denial.

Based on the answers that you give to your representative, they can claim your injury didn't occur at the time of the alleged accident and that you had it previously. The providers can even declare that your injury resulted from a preexisting condition and not an accident.

This is why it is best practice to keep your health in check as you grow older to avoid having any avoidable health conditions. 

About the Author

Imani Francies writes and researches for the auto insurance comparison site, AutoInsurance.org. She earned a Bachelor of Arts in Film and Media and specializes in various forms of media marketing.

About Carex Health Brands

Carex is your one-stop shop for home medical equipment and for products that assist caregivers with providing the best possible support and care for their loved ones. Carex Health Brands has been the branded leader in in-home, self-care medical products for over 35 years. Our goal is to improve the lives of our customers by bring them quality products that bring dignity back to their lives. With our three nationally distributed brands, Carex Health Brands serves national, regional and independent food, drug and mass retailers along with wholesalers, distributors and medical dealers.

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