What would be a reason for an insurance company to deny coverage under a self-funded plan?

In the context of a self-funded insurance plan, an insurance company may deny coverage for several reasons, each of which highlights the unique characteristics of these types of plans. These plans are typically financed by the employer rather than an insurance company and are therefore governed by different rules.

Insufficient documentation can lead to a denial because the claims process in a self-funded plan relies heavily on substantial evidence that supports the claim being made. Without proper documentation, the administrator of the plan may find it challenging to assess the validity and appropriateness of the claim.

Exceeding policy limits may also be a reason for denial. Self-funded plans usually have specific limits established, and if an individual’s claims surpass those limits, the insurance company is not liable to pay the excess amount.

Pre-existing conditions represent another common reason for denial. Many self-funded plans include provisions regarding how pre-existing conditions are treated, and if these conditions are not covered under the plan's terms, the insurance company has the right to deny coverage for related medical claims.

All these factors can contribute to a denial under a self-funded plan, making "all of the above" the most accurate answer in this context. Each reason reflects valid grounds within the structure and administration of self-funded health plans.