What To Do If Your Health Insurance Claim Gets Denied?

Legal News & Analysis - Asia Pacific - Insurance & Reinsurance

2 January, 2020


When you require serious or minor medical care, insurance should be the last thing on your mind. However, you probably have experienced a situation where the insurance company refused to cover all or most of the bill. This doesn’t mean that you should immediately take them to court and demand money.


Unfortunately, the corporation does have the right to refuse claims for several reasons. Luckily, there are many things that you can do that might make them reverse their decision. Here are a few tips to guide you:


Read The Fine Print


People sign up for many different kinds of policies. Health, life, long-term disability, and property insurance, to name a few.


Therefore, you should make sure that there is no confusion by going through every line of your signed agreement before taking any actions. There is a chance it means something different to you than it does to your insurance company. If the company is not providing coverage for something that is clearly written down in the contract, then contact your insurance company and ask them for a proper explanation for their denial. Don’t hesitate to ask any questions if you don’t understand.


Try not to show any anger towards the person on the phone as they are just an employee, and they might even give you advice, that is specific to the company, on how you need to handle the situation.


Contact Your Insurance Agent Or HR In Your Company


Get in touch with the person from whom you bought the insurance, or the manager in the human resources department of the company you work in, and ask their support in challenging the claim denial. They have to make sure that your interests are protected, which is why they can be of great help. It entirely depends on the process, but they will help you understand the claim, appeal process, and benefits. They probably have a much better understanding of the process than you do, which is why they will even contact the insurance company to help.


Contact your doctor and ask them if they will allow you to enlist their support, this can certainly improve your chances of winning.


Take Action Yourself


If the insurance agent and the HR team in your company did everything they could, and it has been over 3 to 4 weeks, then maybe it’s time to call the insurance company yourself. Try not to engage emotionally and be persistent, with a clear mind. Big insurance companies have hundreds of employees, and you may have to talk through many levels of the corporate ladder to try to solve your case. Record all the calls and make sure to note down every detail, like names and position of every person with whom you are speaking in the company, and any reference numbers. Write down everything before you contact the corporation, and keep the policy in-hand as well to quote any writings. After each call, write a letter to the person stating your understanding of the conversation. Start by writing to the supervisor of the employee who denied your claim. Request that they reply to you within three weeks.


Use Your Right To Appeal


If your agreement is not grandfathered, meaning that is was signed before March 23rd in 2010, the Affordable Care Act will ensure your right to appeal any claim denials. You can request that your insurance company conducts an internal investigation in your claim.


Furthermore, you also have the right to an independent external appeal if your insurance provider denied. If you are trying to get a pre-approval for any treatment and the insurance corporation denies the request, you still have the right to an appeal. Your right is reserved for both pre and post-service denials. External reviews can be compelling. That is why many people request the insurance provider for internal, and they escalate their case to an external appeal. Many of these cases come out in favor of the policyholder, which is why you should keep trying.


Ask The State’s Insurance Department For Help


Just like every other, your state has an insurance commissioner whose job is to oversee polices. You can find their information anywhere on the internet. Don’t hesitate to tell them about everything, it is their job to help. Make sure you show them all the insurance documents, which will help them get a better understanding of your case. They will be able to tell you exactly what your next steps should be. Several policies don’t come under the state, but the federal law instead. If you have a case which the commissioner can’t handler, they will adequately examine your situation and guide you in the right direction but not be able to act on your behalf.


However, all the claim denials can be appealed. As long as you signed up after March 23rd in 2010, when the Affordable Care Act was passed, it shouldn’t be a problem.


Make Sure There Were No Mistakes In The Filed Claims


Typically, the hospital or clinic file the claims for their patients. As long as the treatment you are getting, and the hospital comes under the insurance company, everything should go smoothly. The clinic, hospital, or your doctor will handle the claiming process, and sometimes the precertification as well. This is the reason why there is room for errors. The staff could've made a mistake by misspelling something or made mistakes in the application. Therefore, make sure you correctly understand the explanation that is given by the company before taking out your wallet. If the place you are getting treated from is not under the insurance company, then you might have to pay the full price upfront.


However, you can get reimbursement payments from your insurance corporation if it is in the signed agreement. Although corporations don’t generally pay a reasonable amount for treatments that were done in hospitals and clinics they don’t cover, you can challenge them if you feel like they aren’t paying you enough.


Understand The Insurance Company’s Process


Many people mistakenly think that their insurance claims are being denied when they are just paying the out-of-pocket costs. Carefully read the explanation that your insurer sends, it will have details of all the benefits and reasons for why you have to pay some or all of the medical bills.


For instance, your insurance agreement has a $3000 deductible, and you haven’t gone to the hospital all year. Suddenly there is a medical emergency, and you end up with a $1000 bill. Assuming the hospital is in the company’s network, the insurer will inform you that you will have to pay the entire amount because you haven’t met your deductible requirements yet. This doesn’t mean that they have denied the claim.


This is because the company will only pay after you have paid through and successfully claimed insurance on $3000 worth of medical bills in that year. Let's say your next visit to the hospital costs $8000, now if the claim is successful, you will only have to pay $2000 to cover up the deductible and the insurance company should handle the rest.


Hire An Attorney


After going through every single step mentioned above and failing, you can consider hiring a reputable Insurance Denial Attorney. Whether you can sue the company depends on your state and the insurance policy. Take all the following things to the lawyer:


  1. Your entire health insurance policy.
  2. The conversations you recorded with the insurance provider, written and audio logs.
  3. The documents of all the denials made by the insurance company.
  4. An adequately organized set of papers that were used to appeal internally and externally and their respective denials.


Make sure to ask your attorney every detail. Don’t forget to ask them about anything that you should or shouldn’t do after you file for a lawsuit. A lawyer can even help you with previous steps as well, like filing for internal and external appeals. Getting a lawyer may be costly for smaller cases. However, if the situation is significant, having a well-experienced attorney will definitely make sure the odds are in your favor.


Speed Things Up If Necessary


There are many cases when people aren’t able to go through conventional methods. If you require urgent medical care, then you may not be able to wait for the company’s internal appeals and any external appeals to run their full course. You can get the process fast-forwarded by filing for an expedited appeal. It will be accepted if there is a risk to your life, or if the standard requests will jeopardize your ability to regain the most body function. Both the external and internal will be jointly filed in these cases. Sometimes when a patient is unable to carry out the process themselves, the hospital helps them out. That is why you should ask the doctors at the hospital, or any other staff member at the health care facility, to file for any appeals on your behalf.


Amy Rehan is a guest post manager at Globex Outreach. Her job is to ensure all guest post projects are completed on time and according to client’s requirement