Health Insurance Claim Articles

Health Insurance Claim Denied Due To Waiting Period Provisions

By Jeffrey L. Greyber, Esq.

I would like to deliberate on the health insurance arena, particularly, on what I have noticed recently on the rise, health insurance claim denials based on waiting period provisions. According to the United States Department of Labor, Affordable Care Act Implementation Part XVI Section 2704(b) (4) of the PHS Act, section 701(b) (4) of ERISA, and section 9801(b) (4) of the Code, a waiting period can be defined as the period that must pass with respect to the individual before the individual is eligible to be covered for benefits under the terms of the plan.¹

Often times, the insurance companies will attempt to wield a waiting period provision against policyholders, to deny coverage. Most health insurance policies are going to include a waiting period provision. As a policyholder, it is up to you to be mindful of the content of the waiting period provision within your health insurance policy.

This waiting period provision could be something similar to three months or six months, depending. Your specific waiting period provision says that for the stated amount of time, the policyholder cannot be treated within this waiting period and find coverage in the end. A waiting period provision clearly states its guidelines, but there are also a number of exceptions. Emergencies are supposed to be excepted from the waiting period provision. Certain exclusions indeed apply. Do you know yours?

Be cautious, as a policyholder, of your waiting period provision. Perhaps under your waiting period provision you should look into pre-approval or pre-certification for coverage. To avoid these distasteful situations with your insurance company, it is important to fully understand your health insurance coverage.

Health Insurance Claim Articles