Medical insurance coverage

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Medical insurance coverage

Can medical insurance deny a claim is
the surgery is a medical necessity?

Asked on February 11, 2018 under Insurance Law, Pennsylvania

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 3 years ago | Contributor

It depends on 1) the terms of your policy--insurance is a contract, and the insurer only has to pay when, for what, and how much they agreed to pay in the policy; 2) the evidence for medical necessity--does mainstream medical opinion support it (i.e. is it generally accepted as a necessarity), or does not mainstream medicine not accept the value or safety or reliability of this treatment? Generally, your insurer has to pay for accepted treatments covered under the plainn terms of your policy. If you believe they are not doing this, you can sue them for "breach of contract"--that is, for violating their policy/contractual obligations--for the cost of the procedure, if you cannot resolve this through their in-house appeal procedure.


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