Easing the Pain of Insurance Claims
How to fight back when your claim is denied.
It's tough enough being sick, but what can add insult to injury -- literally
- is when your insurance company refuses to pay the bill. Don't assume that's
the final word. By being informed, organized, and persistent, you can often get
insurance companies to reverse course and cover your care.
Step 1: Read your policy and familiarize yourself with
what's covered and what's not. Review the rules concerning issues such as
deductibles, co-payments, and maximums. If you have insurance through your
employer, you can check with your benefits administrator.
Step 2: Call the insurance company and speak with a
customer service representative. As tempting as it might be to give the person
a piece of your mind, remember that being hostile could work against you.
Instead, remain calm and be prepared by having all paperwork easily accessible
along with relevant sections of your policy. Referring to this information,
state your case clearly and concisely.
Step 3: If the insurance rep doesn't seem up to speed or
doesn't give you a satisfactory response, ask to speak with a supervisor. If
that person doesn't help, get the name of his or her boss. If you're told
someone will get back to you with an answer, ask when. Write down the person's
name, extension, and the date you spoke. If you don't receive an answer by the
promised date, call the rep back. Take detailed notes on each conversation so
you can refer to them in subsequent discussions.
Step 4: If you don't get the response you want through
phone calls, the next step is to file a written complaint. Basically, this
includes your name, address, policy number, and doctor's name, along with a
description of what wasn't covered and why it should have been. A note from
your doctor supporting your case can be helpful. Check with your plan to find
out what information is required for a written appeal and where it should be
sent. Get the names of people in charge of patient complaints and appeals, and
address your letters (or, if appropriate, emails) directly to them. Save copies
of all your correspondence. If you don't receive a response within a month or
two, call and ask when you can expect one.
Step 5: If you don't succeed with a written appeal, don't
give up. You still have more options: You can often appeal again and have your
case reviewed by a different set of insurance company representatives. If that
fails, you may be eligible for what's known as external review, offered by most
states. The requirements vary from one state to another. To get specifics about
procedures in your state, consult "A Consumer Guide to Handling Disputes
with Your Employer or Private Health Plan," prepared by Consumers Union and
the Kaiser Family Foundation. It's available online at www.kff.org/consumerguide.
Remember that health insurance companies often issue denials with the
expectation that you won't challenge them, or if you do, you'll quickly give
up. By being persistent and letting them know you intend to keep fighting, you
can often wear them down and prompt them to give up -- in effect giving them a
taste of their own medicine.
Robert Davis, PhD, is the reader's representative. His opinions and
conclusions are his own.