General Discussion
In reply to the discussion: CA health insurance exchange gets $674-million federal grant [View all]eridani
(51,907 posts)There is an appeals process for claims denial, which means that claims denial is legal. In actual civilized countries that have private insurers, the insurers MUST pay every claim, although they can appeal to the government if they think it is unjustifiable. IMO, that's how it should be--the insurance company, not the patient, should be stuck with doing the appeals work.
http://www.bcbsm.com/content/microsites/health-care-reform/en/reform-alerts/appeals-process-standardized-under-health-reform-law.html
For adverse benefit determinations, enrollees have the option of appealing the decision first through their health plan or health carriers internal process, and then externally through an independent party if their internal appeal is denied