How to Appeal a Medical Insurance Claim and Hold onto your Savings

Nothing can eat into savings and impoverish a family like medical expenses. Health insurance premiums, co-pays, limitations and caps and large individual and family deductibles are bad enough, …

Nothing can eat into savings and impoverish a family like medical expenses. Health insurance premiums, co-pays, limitations and caps and large individual and family deductibles are bad enough, but when something catastrophic occurs or you have an debilitating, chronic illness that may require long-term medical care, you learn pretty quickly that your “decent little nest egg” is nothing but a memory. In a worst case scenario, it can wipe out your entire savings, and you’ll find that you won’t have sufficient funds to pay for the required medical care; you may be forced into heavy debt to finance your medical expenses or even need to declare bankruptcy.

Sadly, despite the high cost of insurance premiums faithfully paid, insurance companies tend to nickel-and-dime us, regularly denying claims and forcing us to accept the inevitable or fight for coverage that we expected. If you find yourself on the short end of the insurance stick with a denied claim, here’s how to appeal the claim, and hopefully have the decision reversed.

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  1. Appeal the claim: With luck, the denial will have been caused by human error, which happens all too often as insurances and hospitals are overwhlemed with paperwork. Each insurance company has its own appeals process, which is usually spelled out in your insurance policy or contract. Make sure you follow the guidelines for precisely; insurance companies are quick to reject a claim if it falls into a “grey area.”
  2. Get medical help—your own doctor, that is. Your doctor can provide the evidence required by the insurance company that the care you received or need to receive in a medical necessity. If possible, prior to the treatment, ensure that you get a written confirmation from the insurance company that the associated medical expenses will be covered.
  3. Contact HR: If the medical insurance coverage is through your employer, inform your own human resources department, who may be able to give you a contact name that can speed up the process on your behalf.
  4. Keep records: Record all correspondence between you and your insurance company. For telephone conversations, write down the name of the agent you spoke with, the date, the time and confirm the salient points of the conversation. Follow up either with an e-mail or a letter confirming the conversation.
  5. Put it in writing: Mail a typewritten complaint to the insurance company headquarters, to every name you have on file, including the president of the insurance company, your own insurance representative and the head of the customer service department. All correspondence should be sent by certified mail to confirm receipt. Include copies of all relevant supporting documentation.
  6. Contact the authorities: When all attempts fail, file a formal complaint with your state’s insurance commission or department. In some states, a review panel comprised of experts in the medical field can disallow an insurer’s ruling, compelling them to pay a claim.
  7. Involve an advocacy group: The groups can provide a wealth of support, both emotional and informational, with data and statistics to arm you in your fight.
  8. Negotiate the bill: You ask for discounts when shopping for new cars and appliances, and you can ask for a discount from your medical doctor or hospital. If the insurance doesn’t cover a procedure, ask whether or not payment in cash would warrant a discount, or if you can make regular payments over time. Don’t bother with the billing office: they can’t make the decision. Contact the hospital or medical center business office and see if you can negotiate. The worst they can do is say “No.”
  9. Get a lawyer: An attorney with medical insurance and appeals experience, or who focuses in health law would be your best option. Though hiring a lawyer is not a cheap proposition, it can be significantly less expensive than laying out hundreds of thousands of dollars for medical care.

The bottom line is you’ve got to fight for what you’re entitled to. There’s too much at stake to throw in the towel.



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