When you sign up for insurance you, the subscriber, are required to sign a contract.There is a clause in most contracts that basically gives the insurance company the right to do a retrospective review.
What this means is: Let’s say you go to your physician and your physician recommends that you need a procedure. And of course that procedure is expensive. So as required by the contract you have to present this to the insurance company so they will agree to make payment on your behalf. All paperwork is reviewed and the procedure is approved by your insurance company and they agree to make payment. You move forward and have the procedure and your physician bills your insurance company. Now your insurance company wants a second review because of the expense, so they request medical records to do a retrospective review. Guess what they don’t think the procedure was medically necessary after all so therefore they make no payment on your behalf.
Who is left with the full responsibility of the bill… you! Fair?