What is a coverage denial?

A coverage denial is a denial from an insurance company to provide insurance coverage for a particular health service or product. In Pennsylvania, all insurance companies are required to provide coverage for medically necessary services and products. However, if the company believes that the product or service is not medically necessary, or if the policy does not cover that particular service or product, they may deny coverage. In the event that the insurance company denies coverage, they must provide the insured with an explanation as to why they are denying coverage. This explanation should include an explanation of why the service or product in question is not covered under the policy, and a list of any steps that can be taken to appeal the decision. If the insured is still unsatisfied, they may file a complaint with the Pennsylvania Department of Insurance. In some cases, insurance companies may retroactively deny coverage for services that were already provided. In this case, the insured may be charged for those services, retroactively. The Pennsylvania Department of Insurance provides resources for individuals who have questions about a coverage denial or retroactive denial. It is important to understand all of the details of your health insurance policy before seeking medical services to ensure that you understand the coverage you have.

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