What Is a Medical Policy, and Why Is It Important When Your Insurance Claim Is Denied?
If you’ve had a health insurance claim denied, your insurer may have cited a “medical policy” as the reason. But what exactly is a medical policy, and how does it impact your ability to receive the treatment your doctor recommends? Understanding medical policies is crucial when challenging an insurance company’s denial of coverage, and legal assistance from an experienced insurance law attorney is essential in this complex area. In Los Angeles and statewide, contact Gianelli & Morris for help from an experienced and dedicated California insurance bad faith lawyer who can help you fight back against wrongful claim denials.
What Is a Medical Policy?
A medical policy is a set of guidelines that insurance companies use to determine whether a particular medical treatment, procedure, or service is considered medically necessary and eligible for coverage. These policies are developed by the insurance company itself and are based on a combination of medical research, industry standards, and the insurer’s own financial considerations.
Medical policies outline:
- Which treatments or procedures are covered under an insurance plan
- What criteria must be met for coverage eligibility
- When a treatment is considered experimental or investigational
- Whether prior authorization is required before the insurer will pay for a service
While medical policies are meant to provide guidance, they often serve as a tool for insurance companies to limit their financial responsibility—sometimes at the expense of the policyholder’s health.
How Insurance Companies Use Medical Policies to Deny Claims
Insurance companies frequently use medical policies as justification for denying claims, even when a doctor has determined that a treatment is necessary. Some common ways insurers use medical policies against policyholders include:
- Declaring a treatment “not medically necessary” – The insurer may claim that the requested procedure does not meet its medical policy criteria, even if a physician believes it is essential for the patient’s health.
- Labeling a procedure as experimental or investigational – Insurance companies may refuse to cover certain treatments by asserting that they are not widely accepted in the medical community, despite evidence of their use and effectiveness.
- Requiring strict documentation or prior authorization – Some policies impose burdensome requirements, such as multiple failed treatments before approving a certain medication or procedure. If these steps aren’t followed exactly, the insurer may deny coverage.
Because medical policies are created by the insurance companies themselves, they can be vague, restrictive, and difficult for policyholders to interpret. Insurers may rely on these policies to deny claims in bad faith, hoping that policyholders will accept the denial without challenging it.
Why You Need an Insurance Law Attorney to Fight a Denial
Challenging a claim denial based on a medical policy can be an uphill battle. Insurance companies have teams of legal and medical experts backing their decisions, making it difficult for the average policyholder to effectively dispute a denial.
An experienced insurance law attorney can:
- Review the insurer’s medical policy to determine if it was applied incorrectly or unfairly
- Gather medical evidence and expert opinions to support your claim
- Challenge bad faith claim denials by proving that the insurer wrongfully refused to cover necessary treatment
- Take legal action to hold the insurer accountable for denying a valid claim
Contact Gianelli & Morris to Fight Unfair Insurance Claim Denials in California
At Gianelli & Morris, we represent policyholders in California who have had their health insurance claims denied in bad faith. If your insurance company has used a medical policy to deny coverage for a necessary medical treatment, you don’t have to accept their decision. Contact us today for a free consultation and let us help you fight for the coverage you deserve.
