ABA Family Legal Guide

Health-Care Law

Health-Care Options

Health Insurance and Managed Care Organizations

What are typical problems that arise in getting health-care benefits provided or paid?

Coverage and benefit disputes in health-care insurance and health-care plans that frequently arise include the following:

1. The insurer or plan contends that care was not medically necessary, which is often defined as care that is reasonably required according to accepted norms within the medical community.

2. The insurer or plan contends that the charges were not "usual, customary and reasonable" for the services rendered.

3. The insurer or plan contends that the treatment was "experimental" or "investigational," which generally means that the care has not been accepted in the medical community as normal treatment or has not been proven to be effective medically.

4. The insurer or plan contends that medical care was received outside a specified geographical service area and was not emergency care.

5. The insurer or plan contends, with respect to extended care especially, that the care constituted "custodial care" or "long-term rehabilitation," which usually are excluded from coverage. This issue often arises in the context of persons confined to skilled nursing facilities or persons requiring home health care.

6. Coverage in a replacement policy is substantially and impermissibly different (more limited) than that in a group policy it replaced.

7. There are substantial differences between descriptions or terms in the evidence of coverage (member handbook, disclosure form, or summary) and the insurance policy or health plan contract in the circumstance where the denial of coverage or benefit is based on the evidence of coverage, not the contract.

8. There is substantial ambiguity in a particular term, definition, benefit or coverage description, or exclusion or limitation, or an ambiguity created by an interplay between or among the different provisions.

9. The insurer or plan attempts to effect a reduction in or elimination of a benefit or coverage contrary to a provision in the policy or plan, or without adequate notice.

10. The insurer or plan seeks cancellation of the policy or plan alleging that an insured or member had a preexisting condition not revealed in the application.