Fight for Your Rights:
Health Insurance Claims
It pays to face up to big
By Dan Caplinger, Motley Fool;
MSNBC.com ~ Jan 25, 2007
One of the biggest concerns among those trying to plan their financial lives
is having adequate protection against the high costs of medical care. Many
people go to great lengths just to obtain health insurance, such as working
at jobs outside their chosen profession or accepting low-paying work that
makes them eligible for employee benefits. Because the costs of individual
health insurance policies are often prohibitively high, these decisions make
economic sense, but they're not always the most desirable choices from a
Just because you've gotten good health insurance, that doesn't mean you
never have to worry about medical costs again. Like any other insurance
company, health insurance providers may deny claims if your policy doesn't
cover a particular procedure or type of care. While a recent study shows
that some private insurers, such as Aetna (NYSE: AET) and Humana (NYSE:
HUM), pay claims relatively quickly, they still have higher rates of denials
than do government programs such as Medicare. If your claim is denied, you
need to do a number of things to fight the denial and give yourself the best
chance of getting your claim paid.
Know your policy
The first step in getting the coverage you deserve is to understand as
much as you can about what types of medical services your policy covers.
Even the best health insurance policies don't provide unlimited coverage for
every conceivable medical need. Furthermore, most policies have substantial
limitations and restrictions on benefits for a wide range of conditions, and
many also require you to follow certain rules and procedures to make claims.
Without carefully reviewing your policy, you may mistakenly assume that your
insurance will pay the costs for the medical care you need even if the
policy explicitly excludes coverage.
The best time to acquaint yourself with your health insurance policy is when
you first get coverage. It's easy to procrastinate until you need medical
care, but you won't be at your best once you're ill or injured, and digging
through insurance documents probably isn't how you want to spend your
Follow the rules
Even though many of the procedures that insurance companies require you
to follow are cumbersome, it pays to follow them as much as you can. In some
cases, insurance companies require that you get pre-approval on certain
types of medical care before the care begins. If your doctor advises a
particular course of treatment for a medical problem, get in touch with your
insurance company before proceeding with the treatment, to make sure that
you follow the required guidelines.
However, if you fail to follow the correct procedures, you shouldn't give
up. While not going by the book may make things more complicated, you can
still work to get your claim accepted.
Work with your doctor
When you need medical care, you often rely on your doctor to make an
appropriate diagnosis and suggest a course of action. It's tempting to
extend that reliance to health insurance issues as well. After all, since
your doctor deals with health insurance all the time, you may fairly assume
that he or she knows more about it than you do.
However, with all of the different types of insurance available, you simply
can't depend on your doctor's ability to know what every single type of
policy will or won't cover. The increasing complexity of procedures on
health insurance claims has led many doctors to hire full-time staff members
whose sole responsibility is processing such claims. Ultimately, you're
responsible for understanding how your insurance works.
On the other hand, there are times when you'll be able to work with your
doctor to ensure that your insurance will cover your medical costs. In some
cases, whether you have coverage will depend on how your doctor diagnoses
your medical condition. By telling your doctor what's covered and what's
not, you may get the diagnosis you need so as to get your claim paid.
Dealing with denial
Despite your best efforts, your insurance company may deny your claim.
The first thing to do is to review what your insurer sends you, along with
your medical bills, in search of erroneous charges or incorrect coding of
expenses. If your denial letter doesn't clearly state the company's reason
for denying your claim, call your insurer and have the company explain it.
Keep records of who you spoke with and what was said. In many cases, your
insurer may be willing to correct a simple mistake without much work.
If, however, you find no such errors and the denial appears to be for a
valid reason, you should request a formal appeal from your insurance
company. Each company has slightly different rules for appeals, but many
have fixed deadlines, so don't delay if you choose to file an appeal.
If you lose your appeal, some state governments provide additional oversight
over health insurance plans. Check with your state's insurance department to
get additional assistance with your claims process. You may be able to
obtain an independent review of the merits of your claim by people outside
your insurance company. If you have coverage through your employer, you can
also check with your state's labor or workforce department to see whether
they offer a separate appeals process.
Given the difficulty that many health professionals have in navigating their
way through the vagaries of health insurance, you shouldn't feel bad if you
don't immediately understand everything about your policy. The main point,
however, is that because you're paying for your health insurance coverage,
you should get everything you're entitled to receive. Although that doesn't
mean your insurance company will pay every single medical expense, it's
usually worth the time and effort to stand up and fight if your insurer
unfairly denies a legitimate claim.
What About My Health Insurance??!
The Whole World Is Worried
Not Your Parents' Retirement
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Fool contributor Dan Caplinger has fought health-insurance denials with
mixed success. He doesn't own shares of the companies mentioned in this
article. The Fool's disclosure policy works in sickness and in health.
© 2007 MSNBC.com