No matter what type of health insurance you’ve chosen, or even how good it is, some time or another you may have to defend a claim that your insurer has denied. The claim may be unjustly rejected because of a clerical or other error, and usually a phone call or letter will quickly resolve the matter in dispute. Then there are the times that insurers deny coverage for treatments that are not medically necessary or for treatments that are considered experimental. Be prepared to persist against what at times will seem an impenetrable insurance bureaucracy. Surveys have found that policyholders who contest denials of benefits have at least a 50 percent chance of gaining satisfaction.

Here’s how to protect your rights:

• Keep copies of medical bills you submit with claims. Once you’re notified that a claim has been denied, check over the paperwork for clerical errors, including mathematical miscalculations.
• Ask for your doctor’s help. If the claim is denied because the doctor charged more than is customary, have the doctor write a letter explaining why. If special circumstance were involved, there’s always a chance the insurance company will accept this explanation and pay the claim. If the denial involves medical interpretation, ask your doctor to write to the insurance company.
• If your claim is denied because “medical necessity” is in question, find out your plan’s definition of this. Authorities differ on what medical necessity is and what it’s not. Your best defense against this denial is a second opinion or some other evidence.
• If the insurer labels the treatment experimental and denies your claim, enlist your doctor’s help in explaining why the treatment is no longer, or never was, experimental. You also may want to ask the maker of any breakthrough drug or device used in your treatment to help you prove that the drug or device is not experimental.
• If the insurer refuses your claim on the grounds that the condition existed before the policy was issued, determine whether there’s proof that the affliction developed after you took out the policy. Again, your doctor’s help may be invaluable. Take and keep all notes from phone calls or meetings.
• Put your policy and claim numbers on all your correspondence.
• Keep copies of all your correspondence.

Tags: healt insurance, What to Do if Your Health Insurrer Won't Pay

Posted on Wednesday, August 20th, 2008 at 4:41 pm filed under Health, Insurance.