How do I appeal the rejection of a claim if my health insurer denied to cover treatments after Ireceived them because they considered them a pre-existing condition?

UPDATED: Feb 20, 2012

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How do I appeal the rejection of a claim if my health insurer denied to cover treatments after Ireceived them because they considered them a pre-existing condition?

I received a series of treatments, including physical therapy, MRI and X-rays on my knee. After that my health insurance company refused to cover the these treatments. I’m in grad school and in no way can afford to pay for them myself. Before every procedure, I was given the impression by the doctors’ offices that the procedures would be covered by my insurance and that’s why I underwent all of them. Otherwise, I wouldn’t have done so. But they informed me after the fact.

Asked on February 20, 2012 under Insurance Law, California


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

Answered 10 years ago | Contributor

There are really two issues here: one that the insurance company considered what ever the diagnosis to be a pre exisiting condition and two, that the medical provider mis represented that the treatments were covered.  So you need to do afew  things: you need to file an appeal with the provider and  look in to why they have labeled it pre existing becuase the aw has changed in your favor with regard to same.  Insurers can not always disclaim coverage for that any more.  Next, file a complaint with your state insurance department on the matter.  They can help you.  Next, time to tackle the provider.  You need to file a complaint with your insurer regarding the matter and the state attorney general's office and send a letter by certified mail to them regarding their mis reporesentation.  You can also file a claim against them with the state insurance department and the state agency that licenses them.  Keep on them all.  You should get some results.  Good luck.

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