Can my health insurance deny my claim even with an approved prior authorization?

Get Legal Help Today

 Secured with SHA-256 Encryption

Can my health insurance deny my claim even with an approved prior authorization?

My doctor submitted prior approval for botox to my insurer. The botox is injected at the doctor’s office to treat excessive sweating. I was given gave prior authorization by the the administrating company who handles prescription requests for my healthplan. My insurer then received the medical claim, as I do not pickup the botox from a pharmacy. It denied the claim saying that treatment for excessive sweating is an excluded benefit for the plan I am enrolled in. Can they do this since I was issued prior authorization?

Asked on July 4, 2011 under Insurance Law, Minnesota

Answers:

M.T.G., Member, New York Bar / FreeAdvice Contributing Attorney

Answered 10 years ago | Contributor

Here is where I think that the problem lies: your doctor submitted the prior approval to the wrong portion of your insurance plan providers.  Although the plan may have approved the medication, the plan did not approve the use and the procedure.  So can they dent the claim?  Yes, they can.  Can you fight them?  Yes, you can.  And you need to get n your doctor's back about what exactly they did.  You relied on their expertise to navigate the health insurance waters and they obviously sank your boat.  They had you sign something that has you on the hook should insurance not pay.  But they need to be held accountable.  Good luck.


IMPORTANT NOTICE: The Answer(s) provided above are for general information only. The attorney providing the answer was not serving as the attorney for the person submitting the question or in any attorney-client relationship with such person. Laws may vary from state to state, and sometimes change. Tiny variations in the facts, or a fact not set forth in a question, often can change a legal outcome or an attorney's conclusion. Although AttorneyPages.com has verified the attorney was admitted to practice law in at least one jurisdiction, he or she may not be authorized to practice law in the jurisdiction referred to in the question, nor is he or she necessarily experienced in the area of the law involved. Unlike the information in the Answer(s) above, upon which you should NOT rely, for personal advice you can rely upon we suggest you retain an attorney to represent you.

Get Legal Help Today

Find the right lawyer for your legal issue.

 Secured with SHA-256 Encryption