Insurance Rejection.

By: Taylor


Many people face insurance rejection due to pre-existing health conditions or disability. Some may face discrimination of charges or exclusion of certain benefits due to pre-existing health condition including disability. Pregnant woman also face discrepancy in charges or rejection of insurance due to their condition.

Most states deny health insurance coverage or charge higher premiums or devoid beneficiary of certain benefits due to pre existing health condition including a disability. In some states insurers are prohibited from rejecting insurance due to medical condition. This is known as guaranteed issue. The affordable care act has changed this. By 2014 all new individual plans and all job-based plans are prohibited from denying insurance or charging higher for health coverage for children due to a pre-existing condition or a disability. From 2014 these plans are not allowed to deny coverage or charge higher to anyone because of a pre-existing condition, including a disability. Meanwhile the affordable care act has made provision for people with disability or pre existing health condition through different options. People with a pre-existing condition can qualify for enrolment in Pre-Existing Condition Insurance Plan created under the Affordable Care Act if they have been uninsured for at least six months.

Pregnant women are denied health insurance coverage in most states. The Affordable Care Act has made provision that from 2014, new individual plans and all job-based plans will not be able to reject insurance or charge higher premium due to pregnancy or other health conditions. Meanwhile there is a provision of health insurance coverage for pregnant women along with their new born through Medicare and CHIP. They can also avail insurance through state high risk pool or Pre-Existing Condition Insurance Plans.

Appealing Denials

The Affordable Care Act has also provided consumers with protection against denial of medical claims through right to appeal a health insurance claim denial. In case an insurer won’t pay a claim for medical services the beneficiary has rights to appeal.

Claims could be denied for many reasons including billing errors, missing information, eligibility issues or other such reasons. Insured individuals have right to both an internal and external appeal. After The Affordable Care Act they got the right of an independent third party review too.

If a health insurance claim has been denied, the consumer can appeal and ask the insurer for reconsideration of the denial. The claimant can check out the reason of denial and whether it is justified. If the denial is not right he should go for an appeal.

If the insurance company’s internal appeal process did not work he can go for external appeal. In case of internal appeal not being granted he can file a claim with state’s insurance department. The claimant can also go for an independent third party review.

Many health plans have several steps in the appeal process. In that case if the initial appeal is denied, one can file additional appeals. Consumers enrolled in a job-based plan may require appealing a second time before requesting an external review. If external review comes in favour of the claimant health plan will have to cover the cost of service in consideration.

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