When Health Insurance Doesn’t Cover What It Should: What Every Patient Needs to Know
Even for people with health insurance, surprise medical bills and denied coverage are becoming far too common—and the impact on patients can be serious. Recent research highlights a concerning trend: insured adults are often being charged for services they believed were covered and are not always aware of their right to fight back.
In a recent national survey of working-age adults, nearly half reported receiving a bill or copay for a medical service they assumed would be fully covered by their insurance. Even more concerning, most didn’t contest the charges—largely because they didn’t realize they could.
But here's the surprising part: among those who did dispute these charges, a significant number saw the bill reduced or dismissed altogether. This suggests many billing errors may be due to mistakes or miscommunication—not legitimate charges.
Denied Care, Delayed Health
The issue isn’t just about surprise costs—it’s also about access to care. Nearly one in five insured adults reported that their insurance provider initially denied coverage for a treatment or service recommended by their doctor. These denials weren’t always final; in fact, about half of those who appealed were successful in having the decision reversed, either partially or fully.
Unfortunately, the time and effort it takes to dispute a denial can be harmful in itself. A majority of those affected said the process delayed their care, and nearly half said their condition worsened during the wait.
A System That's Hard to Navigate
These billing and coverage issues are often rooted in a system that’s complicated and unclear. Many patients—especially younger adults and those from lower-income households—aren’t sure of their rights, don’t know how to begin an appeal, or simply feel overwhelmed by the process.
Insurance is supposed to provide peace of mind and protect people from financial harm during health challenges. Yet for many, it’s creating additional stress and uncertainty. The good news? You don’t have to navigate this alone.
What You Can Do
Ask questions upfront: Before receiving care, ask your provider what is covered and what isn’t.
Review every bill: Don’t assume a charge is correct. Errors are common.
Know your rights: You have the right to appeal coverage denials and challenge incorrect bills.
Keep records: Save copies of insurance communications, bills, and medical recommendations.
Seek help if needed: Contact your provider’s billing office or an insurance advocate if you’re unsure how to proceed.
As more patients face these challenges, it’s clear that systemic changes are needed to make health care more transparent and accountable. Until then, empowering yourself with knowledge is the best step you can take.
