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Medical Insurance

Your medical insurance policy is a contract between you and your insurer. The policy outlines what medical benefits will be covered, such as prescription drugs, treatments and diagnostic testing. In return for the premium you pay, the insurance company agrees to pay for the items listed on your policy. Your medical insurance policy also lists what the insurance company will not pay for, and if you need treatments that aren't covered, you are responsible for their cost.

There is a difference between a medical benefit and a medical necessity. A necessity is a treatment or a drug that your doctor deems necessary for your health, and a medical benefit is something your insurer agrees to pay for. In rare cases, your physician may decide that you need care that isn't covered by your policy. The items covered are at the insurer's discretion, and their choices are based on a rough understanding of the care that the average patient needs.

Most doctors will familiarize themselves with the limitations and exclusions of your medical insurance, so they can offer you care options that are covered. However, due to the number of health insurance options available today, it's impossible for a doctor to know the ins and outs of every plan. By learning more about your medical insurance coverage, you can work with your doctor to come up with treatment options covered by your policy.

Take the time to read your policy paperwork; it's better to know what's paid for and what isn't before you get treatment or fill a prescription. Some treatments have to be preauthorized by your insurer before your doctor can perform them. If you read your policy and still have questions, don't hesitate to call your insurer and ask for help. Above all, remember that the decision on whether a treatment is covered will be made by your insurer, not your doctor.

As we said, most treatments recommended by your doctor will be paid for by your medical insurance, but a few may not be. When you need a treatment or a test that is not covered, or if you get a script for a drug that's not reimbursable, your claim will be denied and you will have to pay for the drug or test yourself. If your claim is denied, you can appeal the decision; before you appeal, familiarize yourself with the insurer's appeal process. It also does not hurt to ask your doctor for their opinion, and perhaps a treatment recommendation letter to send to the insurance company. Knowing more about your medical insurance will allow you to work more closely with your doctor and your insurer, assuring that the majority of your medical services will be covered.