2008 Insurance Guide
insurance
Fighting health insurance claim denials

When prevention fails

Assuming you've taken all these steps and are still denied coverage, do the following:

1. Review all the paperwork regarding the case immediately, making sure you understand every aspect. Then, with your paperwork in front of you, call your insurance company. Use the customer service number.

2. The insurance company rep should be able to tell you why you were denied coverage. Make sure you take detailed notes of the conversation!

3. Denial of coverage is often the result of administrative error. If this is the case, you may be able to resolve it on the first call, or with just some minor communication thereafter.

4. Assuming the problem continues, request an itemized bill from the doctor or hospital, and analyze every charge. There are often charges on these bills for services not delivered. If you find any, notify the doctor or hospital immediately to get the bill adjusted. Then, notify your insurer.

Often, however, the denial has been legitimately issued. The insurance company may not consider your medical procedure necessary, may consider it experimental or outside their coverage area. That being the case, it's time to take additional steps.

  • Request a formal review by the insurance company. The customer service rep can tell you the specific procedures required. Then, state your case for appeal in writing, and send the letter via certified mail with return receipt requested. Make sure to do this immediately. Some companies have time limits on when appeal requests can be filed. Don't wait.
  • If the insurance company claims that the cost of your care was above their customary cost, request the doctor's or surgeon's notes. They may show that there were mitigating circumstances in your case that justify that cost. Also, request any other information you need from your doctor to prove your case, and make sure you have it all in writing.

 

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