Why is your insurer refusing to provide you with a service?

Although all policies include the basic coverages of health insurance, you may find that your insurer refuses to cover a service without knowing exactly the reason for the denial. Before claiming the insurance , the first of all is to find out what type of policy you have to know what to expect.

The most common modalities are health insurance with no copayment and health insurance with copayment . The difference is, above all, in the price:  the best insurance without copayments have a more expensive premium, but you will not have to pay for each time you go to the health center or a specialist, as is the case with medical policies with a copayment. You can also find reimbursement insurance, which differ from the previous ones because, although at first you will pay for the service provided, then you will be returned a percentage that can be up to 90% of the amount.

Once you have found out what type of insurance you have contracted, you will have to identify the reasons why it is necessary to send a letter of complaint for poor health service . Both in the cheapest health insurance and in the most complete, you can find yourself in this type of situation. Among the most frequent reasons that insurers allege are:

1. The grace period

One of the most frequent reasons for a company to refuse to provide a service is that the period known as the grace period has not expired, in which the insurer agrees with the client that some benefits will not be covered. Now, you must bear in mind that, despite the existence of this period, the law guarantees that any consumer must always be covered by assistance of an urgent nature , that is, those that, if not provided imminently, could endanger life or the physical integrity of the user.

This exception is indicated in all health policies, in which the insurers recognize that the grace periods will be suspended in an emergency situation .

2. Irregularities in the health questionnaire

When you sign your insurance contract, the company will make you fill out a  questionnaire in order to assess your risk  and, therefore, calculate your premium. Hiding pathologies or being inaccurate in the answers can be a serious error: if at the time of the claim, it is determined that a pathology was prior to the policy, the right to provide the service would be lost and the insurance could not be claimed with guarantees of winning.

However, you should also know that the law only requires the consumer to declare “all circumstances known to him that may influence the risk assessment.” Therefore, you cannot be expected to report something that you yourself were not aware of. In addition, the fact that a question on the form is not answered cannot be interpreted as a negative answer, nor  should it be reported on something that was not asked  in the previous questionnaire.

3. Non-payment of the premium

Not for being obvious it is less important: if a client is not up to date with the payment of their premiums, medical coverage will be reduced or, directly, will  be eliminated  until the situation is regularized.

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