Health insurance provides critical benefits when you become sick or injured. However, some insurers deny perfectly valid claims, which might leave you in shock. After all, you have insurance precisely for emergencies, but here your insurer is denying your claim.
Fortunately, you have rights, and it is sometimes possible to get an insurer to reverse course and approve a claim. Persistence will be key, and you should remember to follow the steps below.
Your insurer should tell you why your claim was denied. Sometimes you will receive a detailed denial letter, but more often than not you will only receive an explanation of benefits (“EOB”), which may be difficult to understand. You should also get out a copy of your policy. It might be posted online. If it is not, and if your health benefits are governed by the Employee Retirement Income Security Act of 1974 (“ERISA”), your plan administrator is required to provide you with a copy of your plan documents within 30 days of a written request for them. (Consulting with an experienced health insurance attorney will help you understand your insurer’s decision and your legal rights.)
Make sure that the insurer is accurately summarizing the policy language. You would be surprised at how many insurers ignore their own policies when denying a claim.
Sometimes, denials are made in error and pointing out the correct policy language can help get your claim approved.
Your policy should also contain clear instructions for how to bring an appeal. Also check your denial letter, which should also contain this information. Note any deadlines and forms that you need to complete. If you have a question, contact your insurer immediately and ask.
You should seriously consider retaining an attorney to assist you with your health appeal if the amount of money at issue is significant to you. An experienced health insurance attorney will be able to help you interpret your legal rights. If your health benefits are provided through your employer or your spouse’s employer, they are likely governed by ERISA, which adds additional complications to the process. An experienced ERISA attorney may be needed.
Your insurer might not really understand the severity of your injury. Often, claims are denied because your condition is not well documented, or your provider has not submitted the necessary pre-approval paperwork to the insurer. Collect test results, x-rays, and doctor’s records. You might need to submit them as part of your appeal.
You should also write down the names and contact information of all doctors who have treated you. Your insurer might need to talk with them, and collecting all of this information ahead of time can help you.
Hold onto copies of all letters. If you speak to someone on the phone, then you should also write down the following:
The appeals process is quite complicated. There are often multiple rounds of appeals, but each appeal has its own deadline, which you must meet. Always find out how much time you have and get your appeal in well before the deadline.
Depending on the circumstances, you might be able to bring a lawsuit against your insurer in federal court. Whether or not you should sue is a difficult decision, which depends on many factors.
At the Garner Firm, we represent members of employer group health plans in disputes. To find out more and determine if we can help, please contact us by calling 215-645-5955. We offer a free, initial consultation.
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