My medical insurance claim was declined – what are my options?

Shine Lawyers New Zealand - Right Wrong

Many people take out medical insurance to give them peace of mind. It can offer protection for the future, reduce financial stress and provide more choice when receiving treatment or surgery. But when your medical insurance claim is declined and your insurance company won’t pay for your procedure or treatment, you may feel hopeless and upset.

Here our expert insurance claim lawyers share some helpful information about your options in these situations. 

What does it mean when a medical insurance claim is declined?

When your insurance claim is ‘declined’, it means that your insurer has either refused to pay the claim or has offered to pay less than expected towards your medical bill. There are several reasons that this may occur:

  • The procedure or treatment or condition is not covered under your Policy 
  • You cannot provide sufficient evidence or proof to support that you are suffering from an illness or condition that is covered under the Policy 
  • You have not paid your premiums 
  • You did not tell your insurer something that they needed to know at the time you applied for insurance and/or at claim time

Many insurance companies do not pay claims if the policyholder has not provided sufficient evidence to the insurer in relation to their claim, or there is a dispute in regards to cover under the Policy. When this happens, it is easy for those affected to feel helpless and suffer severe financial and emotional hardship.

How should you handle a declined medical claim?

If your medical insurance claim has been declined, there are steps that you can take to try and appeal the decision.

1. Find out why your claim has been declined

The first step is to try and find out why your claim has been declined. You should have been sent a declinature letter from the insurer. This letter should set out your insurer’s reasons for its decision to decline your claim.

2. Review your Policy and documents

Once you understand why the claim has been declined, you should start to review your Policy and documents. The documents and Policy should clearly explain what cover you have. There will also be a list of limitations or exclusions, which are things that the Policy will not cover. You may also have some additional exclusions applied to your Policy if you disclosed any pre-existing conditions when you applied for cover. If you don’t have a copy of your policy or insurance documents handy, reach out to your insurer to obtain a copy.

3. Give your insurer a call

If you do not know why your claim was declined or if you have other questions to ask, you can always give your insurer a call.

You might find that you have made a mistake in filling out the claim form or missed something that may easily be remedied. You may also want to ask the insurance representative about their internal review process.

Our tip: If you do talk to an insurance representative, remember, it is always helpful to write down the name of the person you spoke with, the date and what was done or decided.

4. Learn about the review process

Next, you should learn about the review process. The declinature letter should also set out how to review your insurer’s decision. If you’re not happy with the decision your insurer has made, you can apply for a review. You may need to apply for this in writing to your insurer and provide further supporting information to the Claims Manager.

5. Contact the Ombudsman

If you have not been able to resolve the matter with your insurer, you may be able to apply to have the decision reviewed by the Insurance & Financial Services Ombudsman (IFSO). The IFSO resolves complaints about insurance matters and is an independent, fair and free service.

Why choose Shine Lawyers NZ?

If your insurance claim has been unfairly refused or declined, we are here to assist you. Our Insurance Law team are not afraid to take on your insurance company to get the outcome you deserve.

Contact us today

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Angela Parlane, Managing Director of Shine Lawyers New Zealand, works tirelessly to achieve great outcomes for clients. Learn more ›

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