Can an Insurance Company Limit the Medical Treatment I Receive?

Last updated on: January 25, 2018

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Do not be fooled by television advertisements with friendly looking spokespeople and helpful-sounding jingles: your auto and health insurance providers, like all insurance companies, are in business to make money. An insurance company that pays out more in benefits than it takes in through premiums will soon find itself out of business.

As a result, your insurance company or another insurance carrier may attempt to limit what medical treatment you receive for your injuries. This may lead you to wonder, are there any restrictions on what type of treatment an insurer can and cannot ask you to forego?

If you or a loved one has been injured in an accident, call Zinda Law Group at (800) 863-5312 for a free consultation with an experienced personal injury lawyer.

An Insurer Cannot Force You to Forego Treatment

It is important to know that an insurance company cannot prevent you from receiving a particular treatment. Any insurance carrier, whether it is your own insurer or the insurer of the at-fault party, that says you cannot obtain a particular treatment or that attempts to get between you and your doctor is engaging in improper behavior.

Denials of Claims and Limitations on Policies

While an insurance company isn’t allowed to prevent you from treatment, a carrier can indicate whether it intends to cover the costs associated with the treatment.

If you contact your own insurance carrier seeking pre-approval for a procedure, for example, the insurance carrier can tell you that the procedure is not covered by the terms of your insurance policy. Similarly, if you submit a claim to your insurance carrier, the company may refuse to pay the claim if it believes that the procedure or treatment was not covered by the terms and conditions of your policy.

A claim submitted to the at-fault party’s insurance carrier may also be denied if the company believes the procedure or treatment was not necessary in order to safeguard your health and provide you with the best potential recovery. This may happen, for instance, if you undergo experimental treatment or agree to a procedure that has not been deemed necessary by your physician.

What Should I Do If My Medical Procedure or Treatment Is Not Covered by Insurance?

Even if an insurance carrier denies your claim or refuses to preauthorize a procedure or treatment, you are not without options. Depending on your situation, you may be able to:

  • Appeal the denial internally: Every insurance company has an internal process through which you can appeal a denial of your claim or other unfavorable decision. You must act quickly, though, as this appeals process has strict deadlines that must be satisfied before the company will reconsider its decision.
  • Present your case to an independent body: Depending on your state of residence or the state in which your claim is filed, there may be an independent body whose members act as arbitrators in insurance claims disputes. Generally speaking, you and a representative for the insurance carrier would present your case in an abbreviated manner. The person or board would then render a decision that would be binding for both you and the insurance company.
  • Seek compensation through a personal injury lawsuit: If another person caused you to suffer the injuries requiring treatment, a successful personal injury lawsuit may result in a monetary award that compensates you for any expenses not covered by insurance. Note, though, that you would still remain responsible for paying any such medical expenses when they are due; failing to do so can lead to serious consequences for your credit score.

Zinda Law Group Can Help You Navigate the Insurance Claims Process

At Zinda Law Group, our experienced personal injury attorneys have helped guide countless injury victims through the insurance and legal processes and assisted them in recovering compensation for medical bills, property damage, lost wages, pain and suffering, and more.

Call us today at (800) 863-5312 for a free consultation with a skilled personal injury lawyer. Meetings with attorneys by appointment only.