Can my health insurance deny my claim even with an approved prior authorization?
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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 12 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.
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