You did everything right. You got the good job with the good benefits. You pay your outrageous monthly premiums on time, every time. You've always believed that you had a safety net, a promise that if you ever really needed it, your "good" insurance would be there.

Then the letter arrives. The one from your PPO plan, filled with bureaucratic jargon, that says the psychological assessment your child desperately needs is "not medically necessary."

The safety net vanishes. The rage begins.

It's Not a Bug. It's a Feature.

Welcome to the American health insurance industry. It is a system built not on care, but on a calculated, profit-driven model of risk aversion. The confusing rules, the endless phone trees, the arbitrary denials — they are not bugs in the system. They are the system.

And the research quantifies the damage: the single greatest barrier to diagnosis is the prohibitive financial cost, with assessments running into thousands of dollars and rarely covered by insurance for adults. This isn't a policy gap. It's a strategic barrier that ensures millions of people never get the answers they need.

"Medical Necessity": This is not a clinical term. It is an economic one. It is a moving goalpost, a deliberately vague phrase co-opted by insurance companies and wielded by their armies of actuaries to deny claims for anything that isn't the most acute, visible, and easily quantifiable crisis.

You Are Not a Customer. You Are a Line Item.

You believe you are a valued customer who has been unfairly denied a covered service. This is a fundamental misunderstanding of the relationship.

You are not a customer; you are a line item on a balance sheet.

From their perspective, your child's well-being is a potential cost, and their fiduciary duty is to their shareholders, not to your family. The denial of your claim is not a mistake; it is their business model working perfectly.

"The insurance industry is playing a shell game, and they count on you being too exhausted, confused, and overwhelmed to follow the ball. Our job is to show you exactly where the ball is."

Fight Back With Strategic Precision

Stop arguing with them on their terms. Start fighting back with strategic, documented precision. Ask them these questions on a recorded line:

  • "Please provide me with the specific section of my plan's policy document that excludes this type of diagnostic assessment."

  • "What is your company's specific, written definition of 'medical necessity' for this service?"

  • "What is the name and license number of the clinical professional who reviewed and denied this claim?"

The insurance company is not your partner. They are the gatekeeper. It is time to find a way to bypass the gate. Learn about the tools they don't want you to know about, like the superbill and our transparent, private-pay model. When you're ready to fire your insurance company as the gatekeeper: We're here →

Part of: Cost & Insurance → | Related: Anatomy of a Cash Grab · The Superbill Guide