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TexLaw
TexLaw, Attorney
Category: Legal
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Experience:  Lead trial/International commercial attorney licensed 11 yrs
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My insurance company has denied a claim for a behavior health

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My insurance company has denied a claim for a behavior health stay at a hospital. I talked to my insurance company and also the hospital concerning this. I received the same answer from both the hospital and my insurance company, that the denial was based completely on age. Apparently, their is a clause which they quoted me stating that the insurance would not cover claim for behavior health claims for anyone except those between the ages of 18-56. I am 58. Is this against our constitution. I live in the state of Utah, and the insurance company is AARP Medicare Complete, insured through United Health Care.

Thank you for responding.
Hi,

Thank you for your question. I need some further information from you before I can answer your question.

When you say "behavior health" are talking about a claim for mental health related services, i.e., psychological or psychiatric treatment?

I look forward to hearing back from you.

-ZDN
Customer: replied 4 years ago.

Yes. It is indeed a mental health claim.The hospital is Pioneer Valley Hosp.


 


Pamela

Thank you for your response.

Whether or not a mental health claim will be covered by your health insurance policy depends on the terms of that policy and is generally considered a matter of private contract law as opposed to constitutional law.

In this case, there appears to be a term in your health insurance policy that limits the availability of mental health benefits to insured's of a certain age. Protections against age discrimination do not apply to this type of situation. Generally, a health insurer can limits its agreement to provide certain health insurance benefits based on the insured's age. I have read an online version of the policy and do not see any age limitation to mental health benefits.

You should take a look at your policy to make sure that this limitation is actually in the policy you have. If it is not, then you need to appeal the claim decision with the insurance company.

That being said, the short answer is that this does not violate the federal or state constitution.

Please let me know if you need further information.

-ZDN
Customer: replied 4 years ago.

Please explain your answer further.


 


Thanks


 


Pamela

No problem.

The type of coverage you have under your insurance plan is determined by the exact statements of coverage located in the policy. These are generally done in stating that they will provide you with certain medical benefits up to a certain limited amount and/or during a certain specified period. In your case, the insurance plan seems to have a limitation on behavior health benefits which terminates when the insured turns age 56.

Do you have a copy of your insurance policy that you can reference? If so, please read through it to the behavior health section and see if you can find this limitation that they are quoting to you.

If the limitation is not in your insurance policy, then they are incorrect in denying your claim. In that case, we need to talk about how you would appeal the denial of benefits and request a written coverage determination from someone higher up in the insurance company.

If you don't have your policy, or are having a hard time reading the policy and find it confusing, the best thing you can do is simply appeal the denial of the claim and ask for them to provide you with written evidence that the claim is not covered.

Please let me know if you need further information or want to talk about how to appeal the denial of your claim.

-ZDN

TexLaw and 4 other Legal Specialists are ready to help you

Hi, please let me know if I've answered your question satisfactorily or whether or not you need some more help.

 

-ZDN