In some cases, the insurer may find reasons to deny claims related to health problems that it claims are not covered or not recognized. In 2013, the state of California went after Health Net Inc., Anthem Blue Cross, and Blue Shield for not covering speech therapy and other medically necessary therapies for patients with autism. The situation was so bad that upon independent review, of 36 flagged cases remaining after one insurer reversed five insurance claim denials, 35 were deemed medically necessary. In other words, in 35 of 36 denials, the insurance company wrongly denied treatment.
There are several conditions that insurers seem to routinely flag as being not recognized or not covered. Among them are fibromyalgia, chronic fatigue and post traumatic stress disorder, both of which can have debilitating, life-altering effects on the policyholder - including inability to work.
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Or the insurance company may claim that even though it recognizes the fibromyalgia diagnosis, the condition is not debilitating and the patient can, therefore, work.
In all cases, it can take a lengthy appeal process and/or lawsuit to force the insurance company to pay the policyholder his or her benefits. In the meantime, the policyholder may have either forgone necessary treatment due to a lack of funds or may have wracked up additional debt to pay for necessary treatments.