Can health insurance deny a claim that was caused by an auto accident?

Your health insurance company can deny a claim that was caused by an auto accident. The reason that some health insurance companies don’t pay has to do with insurance company rules.

There’s no question that many people don’t understand health or auto insurance. Unless you’re knowledgeable of the practices and terminology of the insurance industry, reading an insurance contract is challenging!

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What is the health insurance company obligated to pay?

Auto insurance laws and health insurance laws may vary. The health insurance company owes the insured person two kinds of payments. The health insurance company should pay its policyholder costs of health care provided as a result of an accident.

The health insurance company should rightfully anticipate reimbursement from the insured when she recovers general damages (the actual cost of medical and health care) sustained as a result of the accident from the driver at fault and/or from his auto insurance company.

Medical payments sustained by the injured driver or the driver at fault should be covered by the medical portion of the auto insurance policy.

The insurance company is obligated to pay for the medical care of drivers injured (the insured and/or the other driver(s) injured in the accident).

Why do health and auto insurance companies deny legitimate car accident injury claims?

In other frustrating instances, the auto insurance company may decide to deny medical claims payments to the policyholder or other parties injured in the accident.

The auto insurance company may decide to investigate the medical claims of the injured persons and conclude that the injuries were sustained prior to the accident.

The insurance company then supports the decision with the prospect of potential litigation. Many injured persons may simply back down at that point.

The insurance company saves the payment of owed health insurance claims because it threatens to sue the injured person or persons.

Of course, injured persons may seek the assistance of qualified attorneys to communicate with the insurance company.

Unfortunately, because the parties need immediate help, the thought of future compensation for medical payments (called general damages) may seem less important than simple, immediate medical care.

How does an insurance company disqualify medical claims from an auto accident?

The insurance company may use two ways to attempt to disqualify the insured or injured person(s) medical claims:

• First, the company will demand release of the insured’s medical records to determine any information about previous illnesses or complaints
• Next, the company will require that the insured or injured person meet with a company-determined physician

Though the company says it wants only to ensure that just amounts of claims are compensated or to prevent medical claims fraud, injured persons may suffer additional stress during the insurance company’s claims process.

Medical review companies may provide an impartial review of the injured person’s medical records. However, attorneys for the injured person may take a different view of the process.

When the medical review company performs a significant volume of paid medical review work for the insurance company, their analyses may not be impartial or fair.

When a driver injured in an auto accident seeks medical care, her auto insurance policy should pay the bills.

If the driver doesn’t have auto insurance but has health insurance, her health insurance policy may decline to pay for her health care. Unfortunately, a health insurance company can deny a claim that was caused by an auto accident.

How can injured drivers pay for needed health care?

You have options other than auto insurance and health insurance. Injured drivers in an auto accident may take advantage of a pre-tax medical spending account to pay for health care until the auto insurance payment for health care and medical bills gets sorted out.

If the injured driver has no medical or flexible health care spending account, she should contact a local community health care center to obtain medical attention as soon as possible.

If no other financial resources exist, the injured driver may obtain medical attention through an emergency room under the Emergency Medical Treatment and Active Labor Act (EMTALA) passed in 1986.

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