A claim denial occurs when a health insurance company refuses to pay for a medical service, treatment, or expense that a policyholder has submitted for reimbursement or coverage. When you receive medical care and submit a claim to your insurer, the company reviews the request to determine if it meets the conditions outlined in your health insurance policy. If the insurer decides that the claim does not comply with the policy’s terms—whether due to coverage exclusions, missing documentation, or other reasons—they will deny the claim.
A claim denial means you are responsible for paying the full cost of the service or treatment out of your own pocket unless you successfully appeal the decision or negotiate a resolution with the insurer.
Why Claims Get Denied
Insurers may deny claims for various reasons, including:
- The medical service is not covered by your plan.
- The treatment was deemed not medically necessary.
- You failed to obtain prior authorization when required.
- The claim contains errors or incomplete information.
- The provider is out of the insurer’s network.
- Your policy lapsed due to missed premium payments.
What Happens After a Denial?
When a claim is denied, the insurer must provide a written explanation detailing the reason for denial. You have the right to review this explanation, challenge the decision through an appeals process, and request additional reviews if needed.
Understanding what a claim denial means and why it happened is the first step toward resolving disputes and ensuring you receive the health coverage you are entitled to.