You Can Fight Insurance Denials — 1/28/08

You have undoubtedly had an insurance claim rejected by your insurance company. Everyone has. Some of us may make a call or two to argue with the bureaucrat, but most of us give up and just pay the bills.

Today I want to tell you to fight back. You can appeal a coverage denial, and you can win. But you have to know the tricks of the trade.

First step is to check your rights under your insurance policy. The policy will tell you what is covered, and how to challenge the company's decisions. If you don't understand the policy language, don't feel bad. Most lawyers don't understand the language. For help, call the insurance company's customer relations number.

Next, call the insurer at the number on the denial form. Try to explain why the denial was wrong. One call may lead to a second, a third, even dozens more. That's sometimes called A getting the run around. But keep a log of each call, the name of the person you talked to, and the substance of the conversation.

Your third step is to request a copy of your entire claim file from the health plan. That should include the company's reasons for rejecting your claim. Armed with that information, you can prepare your written appeal.

That's the next step, a written appeal. Make sure you get this in within the company's fixed time limit.

Your written appeal should include rebuttal evidence. For example, if the file says your treatment was unnecessary, provide medical records and a letter from your doctor sharing why the treatment was needed. If the file says your treatment is A experimental,@ attached articles showing that the treatment has been effectively used for a period of time.

You can also get help from the advocacy organization for your disease, such as the Alzheimer's Association, the American Heart Association, or the American Diabetes Association.

Finally, you can ask for an independent medical review. Find out how to do this from the Ohio Insurance Department.

The most important question is: can you win. If you go through all this effort, can you obtain coverage? The answer is, sometimes you can. Not always. But nationally about half of all appeals are successful.

So don't give up. You can fight the insurance company. And, sometimes, you can win!