Why do insurance companies like to denied insurance claim? what are the possible solutions to a denied claim

After all, with the expectation of an accident in the future, I bought an insurance, and the result was a denied insurance claim. Who can resist?

This is more uncomfortable than the virtual currency serial explosion, and I can’t wait to put the insurance company on the street lamp to sing a song “Star Light”.

what to do when car insurance denies claim

But why does the insurance company denied claim, is it because of the refusal to make money?

Can be said to be, or not, the score situation.

Because the money paid is also one of the costs to be considered by the insurance company, it is said that the rejection can make money, in a sense, it is also true. As anti-consumerism says, saving money is worth making money.

However, there will be no insurance companies who are so sick that they can make money by denied insurance claim.

This is too inefficient. You said that you are trying to make a legal license plate, in order to do this thing, it is not cost-effective.

What’s more, the key point is that the main profit of life insurance companies comes from the investment income brought by insurance floating deposit, which, to put it simply, is the money earned by diverting a part of the premium to invest, this is the largest part of the source of revenue.

health insurance claim denied what next

For example, if you buy an insurance, you pay 5000 of the premium a year, and then under normal circumstances, there is a time difference between the time when you buy the insurance and the actual settlement.

You may be at risk for 10, 20, or 30 years, or you may not use insurance at all.

During this period of time, the funds were retained in the hands of insurance companies, and some were allowed to invest in stocks, bonds, real estate, enterprises, and so on, the scope of investment can be more.

So, the insurance company is not to rely on the loss of claims to make money, but there is no need to do so. Insurance companies should pay the cost, you have long been calculated in the premium you have to pay, a steady income is not lost, why play a game of refusal, play a financial game is not sweet.

partially approved insurance claim

If you think in this direction, the pattern is small.

But that being said, actually in the claims, I have seen the case, or there will be a lot of strange phenomena, such as insurance companies will be unreasonable to denied insurance claim.

What is unreasonable refusal to pay? In some cases, you clearly think that the claims, the third party also think that the claims, even the insurance company also think that the claims, but eventually gave you a rejection.

Why? Do you mean to give the customer a hard time?

No, it is mainly because it should not compensate, not an objective decision.

It is a subjective decision made by the claimant.

Historical experience tells us that when it comes to people involved in decision-making, things get complicated.

First of all, we have to know that the corrector is the assessment indicators, will assess the “claims rate, claims cycle, closure rate” and so on.

home insurance claim denied

In general, the purpose of the insurance company to set up these assessments is two, one is to reduce the cost of claims, one is to improve the efficiency of claims.

What does it mean to reduce the cost of claims? If you find out all the problems, you will not pay much. When you encounter a dispute, we will try our best to use negotiation, legal and other means to reduce the cost of payment.

For example, the most typical is that some people take the insurance and get out of danger, and then the insurance company refused to compensate, and the other party gave a round of evidence that the previous abnormalities were not related to the occurrence of serious diseases, and I don’t know the health advice, you have to compensate.

insurance adjuster deny claim

At this time, the discussion began, and the insurance company also knew that if this situation goes to the court, most of the courts will be awarded full claims, and then lose the men and the soldiers, and deal with the cost of the litigation.

Therefore, I would be more willing to send people to discuss with the insured person, and say that you are also wrong. Otherwise, in line with the principle of humanitarian, the premium will be returned to you. If the other party agrees, the matter is over.

hail damage denied insurance claim

If the other party does not agree, the insurance company will talk again, this situation is wrong, I am not suitable for full claims, otherwise, I will compensate you half, this is my final bottom line, if you don’t accept it, you can prosecute us.

Then at this time, the general attitude of the other party collapsed, thinking that there is always better than no, also accepted.

For the insurance company, the case was closed, and the cost of payment was reduced.

how do i respond to a denied insurance claim

You never think of it, do you?

Most of the time, the denied insurance claim is the beginning of the claims.

And then improve the efficiency of claims, this is a good understanding.

Is to shorten the period of claims, a case up, quickly review, not pending, causing procrastination. The case is stuck with you. There’s no progress. What are you stuck in?

Therefore, some people say that they are worried about the limitation of claims, but they really think too much. Whenever there is a company that has an assessment system, the time will not be late. I don’t know if the audit does not understand your mood, but he must know a lot about KPIs.

But interesting things come, you see two assessment, one to reduce the cost of claims, one to improve the efficiency of claims, these two contradictions? There is no contradiction, the work is like this, it is necessary to have a pure capital taste.

But a conflict? Conflict. Complex work, it is impossible to do fast and good.

health insurance claim denial reasons

Therefore, in the process of actual claims, there will be a lot of difficult to understand in our view, such as some claims can not be compensated, or there are cases of doubt, insurance companies usually like to denied insurance claim.


First, the denied insurance claim is an insurance approach

There is a saying that the case will not be resolved, and the decision to denied insurance claim.

For the claimant, there are some cases that are not sure, such as the insured person has a history of purchasing high blood pressure drugs before the insurance, but there is no history of diagnosis of related diseases. At this time, you suspect that he is insured, but you don’t have much evidence.

Ask if you should pay? How to make the right judgment as soon as possible?

It is difficult for you to judge, the claims of non-claims, is wrong.

denied life insurance claim

Should not compensate for the loss, is also wrong.

What would you do if it were you? You will be more inclined to denied insurance claim.

If you are not satisfied, you can appeal. I can ask you to provide more information.

However, if the loss is not due, the money will really go out. If the case is found to have any doubt in the future, it is the insurance company employee, so sometimes knowing that claims can be paid, will still choose to denied insurance claim.

At this time, the denied insurance claim is a decision to maximize the benefits.

It can be understood that human nature is to take advantage and avoid disadvantages.

car insurance claim denied

Second, refusal is also a psychological game

Each of the people who were rejected said that they did not know the health of the informed, absolutely no sick insurance.

I believe that most people are indeed misdirected by sales, but there are also some people who are adverse selection insurance, such as the disease found out just want to buy an insurance, try to lie to the insurance company’s money.

This group is absolutely not a minority, every year there are a pile of waiting period to apply for claims, their idea is very simple, a beat, a bicycle to motorcycle.

If the insurance company compensates, I will lose it. If the insurance company does not compensate, I will lose a few thousands of premiums at most. This is really nothing. Sometimes a day’s stock loss is more than this money.

denied homeowners insurance claim

Therefore, once you encounter a case like this, the insurance company’s practice is to denied insurance claim in the event of a risk soon after the waiting period, the income is not high, but the amount of insurance is high, and the past medical history is questionable, then look at your reaction.

In general, if the insurance is really fraudulent, I know the loss, usually a look at the rejection, or the insurance company to panic, fear of being exposed, will not be pursued.

This is actually a kind of psychological game, the first malicious fraud to the screening out, leaving a low suspicion of fraud and then slowly check.

health insurance claim denied what next

Third, denied insurance claim is a helpless approach

Every insurance company has a standard for each company, some ambiguous cases, in this family can compensate, in that family can not compensate, this is also true.

But only in cases of doubt and controversy.

If you encounter some of the audit claims is more stringent companies, the claims will give the result of the rejection, in fact, is a kind of helplessness, at this time he may let you go to prosecute the insurance company.

As soon as you come up, you have to prosecute the insurance company. It sounds very upbearing, right?

However, such insurance correctors are not bad.

denied health insurance claim

Most of the time, the claimant asks you to prosecute, not insolent, but rather a hint.

He is making it clear to you that, in my place, according to my rules of work, you must not go through this case, but if you go to prosecute, you have a good chance to get claims, even 100%.

On the contrary, deliberately dragging you, playing a cat and mouse game with you, wasting you a lot of time, and then tell you that there is no way to lose.

This kind of person, is really bad.

What if we do have a rejection?

Don’t worry, it’s really not a big deal.

There are several types of cases of rejection, in fact, adhere to it, a high probability of being able to win the payment. Even, the probability is conservative.

what is a rejected claim in medical billing

For example,  the abnormality of the insurance with the disease is not related to the dangerous disease

Will insurance for sick patients denied insurance claim? Will.

But can you pay for it? Common sense is not, I usually say no, this is mainly to encourage everyone to take the disease insurance.

However, in the actual claims scenario, if there are some small abnormalities before the insurance, and the abnormality is not directly related to the disease of the claims, the probability of the claims is very large.

For example, Lao Wang had a medical record of abnormal uric acid before the insurance, and then when he bought the serious disease insurance, he was asked about the abnormal physical examination in the last 2 years, I bought the insurance.

A year later, he was found to have gastric cancer, and the insurance company refused to compensate for the reason that he had not told the “abnormal uric acid” before Insurance. Lao Wang felt that the abnormal uric acid had no correlation with gastric cancer, so he continued to communicate and appeal, finally, the full settlement was obtained.

what are the possible solutions to a denied claim

In this case, I have a little extreme. In general, the long-term serious disease insurance payment will not be so harsh, and there are few cases of small abnormal rejection, but there is indeed this probability.

You never know what kind of correctors are wrong.

However, if it is a short-term medical insurance, such as a million medical insurance, the probability of a similar situation will be rejected, mainly because the business logic of short-term health insurance is not the same.

Short-term health insurance can not bring a long period of available funds to the insurance company, so whether the insurance business is profitable, the main point is the comprehensive payment rate, which will lead to the insurance company in the payment rate and the cost of payment, the card is very strict.

Often a little bit of a small matter, often denied insurance claim.

In any case, millions of medical insurance are basically “wide entry and strict exit”, insurance is easy, strict claims, we must have a bottom.

denied claim health insurance

Second, the purchase of long-term insurance, continuous insurance for more than two years

If the insurance is a long-term personal insurance, such as life insurance, serious illness insurance, term life insurance, etc., and then continue to cover more than 2 years, the body problems, as long as it is not malicious insurance, even if there is a mild case of sick insurance, insurance companies also have to pay.

This is a legal basis, this law is called: “two years can not defend clause”.

If the applicant wilfully or for gross negligence fails to perform the obligation of providing information faithfully as provided in the preceding paragraph, which is sufficient to influence the insurer’s decision on whether or not to agree to underwrite or to increase the insurance premium rate, the date on which the insurer becomes aware of the cause of termination shall be as, after 30 days, the patient was destroyed. Where the date of establishment of the contract is more than two years, the insurer shall not terminate the contract; If an insured event occurs, the insurer shall bear the liability for claims or payment of insurance money.

Literally, even if it does not comply with the health notice, as long as the insurance for more than 2 years, the insurance company may not denied insurance claim.

The truth, as the case is, is not what you think.

However, the premise of the court’s judgment is that there is no malicious fraud.

How to define whether malicious fraud? To see whether there is a subjective, or objective purpose of fraud.

For example, there is a serious illness before the insurance, and it is hard to apply for claims after two years, which is a typical malicious fraud.

And there are really such people, you have to feel, money is the real miracle of life.

insurance denied claim

In case 3, the payment should be made objectively, but the insurance company denied insurance claim on the basis of the definition of the terms

How to understand?

That is, in accordance with the prevailing medical diagnosis and the severity of the disease, in the objective has reached the criteria for the identification of a major disease, but the insurance company does not comply with the definition of the terms of the rejection.

In simple terms, the doctor and you think that the disease is serious to the point of severe illness, has been life-threatening, but the insurance company that does not meet his standards, do not pay claims.

This article is mainly aimed at the risk of serious diseases.

Let me give you a simple example.

Wang 14 years to buy a serious disease insurance, 18 years because of serious kidney disease hospital, in the hospital one month after the unfortunately died, after the family to the insurance company to apply for claims.

health insurance denied claim

The insurance company denied insurance claim because although Wang was diagnosed with end-stage renal disease, however, they did not meet the defined criteria of “regular dialysis treatment for at least 90 days” or “renal transplantation performed.

Indeed, the old Wang only a month of dialysis treatment, up to the standard of this claim.

But the question arises. Is the kidney disease of Lao Wang serious? Very serious, people have died of irreversible renal failure, you have not reached 90 days of dialysis treatment to refuse claims, this is not talking?

How many days do you think Wang himself would like to stay longer?

Therefore, the family of Lao Wang believes that the insurance company is unreasonable to denied insurance claim. After the prosecution of the insurance company, the final court considers that the refusal of the insurance company is not in line with common sense and should be paid in full.

how to appeal a denied insurance claim

The three kinds of claims that I have mentioned above are all related to the case of the ruling. Basically, the court will stand on the side of the weak side.

However, there is no need to be too pessimistic, from the statistical data, the average annual claim rate of insurance companies is about 98%, there are 100 cases, 98 have lost.

In the remaining cases of refusal, the most important is the failure to meet the health notice, followed by the risk during the waiting period, and then the accident is not covered.

And these are all clear things that can be confirmed before the insurance.

Therefore, the most important thing is to make a good health notice before the insurance. If you have any past medical history, please check it.

how to fight a denied insurance claim

Of course, if you encounter an unhealthy insurance company one day, it is unreasonable to denied insurance claim, then there is no fear, there is still a lot of room for this matter, as far as I have seen the case, as long as it is not a fraud, there will always be a solution to the insurance company’s adherence to communication.

Even some of the fraud, a see was rejected, a trouble can return the premium, do you believe?

A child who will cry always has sugar to eat.

Don’t be anxious, just do it.

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