Easing the Pain of Insurance Claims

How to fight back when your claim is denied.

From the WebMD Archives

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.

WebMD Magazine - Expert Commentary


© 2005 WebMD, Inc. All rights reserved.