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Patient Advocate Foundation
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Even if you have health insurance, there may be times that you find yourself having problems being able to access necessary treatments or procedures due to your insurance plan, denying coverage. In this section we will be discussing
access to care issues which you may be experiencing as a result of the following:

  • Capped benefits
  • Non-covered service or insurance denial
  • Catastrophic health insurance plan coverage

You may find yourself in a situation where your insurance company is denying payment on your claim or not giving approval for services being ordered for you due to a specific benefit being exhausted or "capped out." If this is an issue for you, first review your health insurance policy to determine the length of any benefit cap limitation period. You need to determine if the specific benefit has an annual limit or a life time maximum. Depending on the medical urgency and with the approval of your physician, you may want to consider delaying treatment until such time as the benefit renews. If the benefit does not renew or it is not in your best interest to postpone treatment, you would need to consider self-paying for the treatment. Negotiate with your provider for a self-pay or prompt-pay discount.

Your insurance company may deny reimbursement for a specific treatment or service. Every insurance plan contains a definition or list of services they will not allow payment for due to being a "non-covered" service.

As a consumer, you have the right to appeal any insurance denial and provide additional information that may allow the insurance carrier to reverse their original determination. In order to do this, you will need to determine the specific reason for the denial. You will need to submit your appeal based on that specific reason. For example, if the denial is based on not being a covered benefit under your insurance plan, trying to convince the insurance plan that the requested procedure or treatment is medically necessary will not affect the final outcome of the appeal. PAF has a publication entitled Your Guide to the Appeal Process that may be beneficial if you are finding it necessary to submit an appeal.

You may have purchased a health insurance plan that only offers limited benefits or what is known as "Catastrophic" health benefits. You may want to consider the following action steps if your health insurance plan provides limited or no benefit coverage:

Below are resources that may be beneficial in securing coverage or access to care:

  • Conversion Plan: Upon termination of the 18 month period of COBRA coverage, the plan member may be able to convert the policy to a private limited benefit policy. Contact your health plan.

  • Group Health Benefits/COBRA: Determine if health coverage is available through you or your partner’s employment or through a COBRA plan if you or your partner has recently left employment. For additional information you can visit or call 1-866-444-3272.

  • Risk Pool Coverage: Apply for Risk Pool Coverage which provides health insurance options for high risk individuals. These are state programs that serve people who have pre-existing health conditions that often are denied or find it difficult to obtain affordable coverage in the private market. Contact your State Commissioner or access the following link to determine
    which states offer such coverage. Some states have a waiting period.