You might be startled and frustrated when you discover that the medical or health insurance plan you've been researching or the medical claim you just submitted is suddenly declined. Understanding the basic reasons why a health or medical insurance provider might decline to cover you or your needs can help you make better choices and consider additional options when it comes to your health and wellness medical care. Although medical health reform is underway, it might be years before you have options for medical insurance that meet all scenarios and needs.
Pre-existing Conditions
Some health insurance companies are hesitant to insure individuals seeking policies and coverage if they've already been diagnosed with what are known as pre-existing conditions. Such conditions can include diabetes, chronic heart disease, AIDS or cancer. Such conditions are known as high-risk in the insurance industry, according to Corpus Insurance. Carefully research exclusions lists from major health-care insurance providers or ask about their exclusions for coverage before choosing a health insurance plan.
Newborn Birth Defects
Newborns or infants born or diagnosed with birth defects such as heart, lung, brain or circulatory issues might be denied medical insurance or health coverage. In such cases, some insurance carriers claim that infants are born with pre-existing conditions, which exclude them from coverage, according to the CBS News article "Newborn with Birth Defect Denied Coverage," CBS News Special Report, March 26, 2010.
Lifestyles
Some insurance companies will decline to cover you if you engage in dangerous activities such as a motorcycle stunt driver or a habitual mountain climber. Occupations and lifestyle or hobbies that are potentially dangerous, such as extreme skiing or race car driving, might not be insured by traditional medical insurance carriers. Those engaging in habitual lifestyles such as drinking or smoking who have been diagnosed with medical issues resulting from such lifestyle habits might also be denied, according to Action and Smoking on Health, also known as ASH.org.
Elective Procedures
Elective procedures are not necessary to preserve health and wellness. An example of an elective procedure is a breast augmentation. These types of procedures are voluntary and are most often performed for aesthetic reasons but not for a medical necessity. Medical necessity is defined by Medicare as a procedure or service that aids body function, according to Nancy Miller, writing for "Physician News." When in doubt, obtain a Certificate of Medical Necessity from your health-care provider if you're not sure a service will be covered before you accept or agree to the procedure or treatment.
Member Comments