Getting your health insurance company to honor a claim that they are disputing can be a very tough battle. To win your case can be a very long and difficult possible, but it is still possible and definitely worth it, considering the ever-increasing expenses of health care. Follow these steps to help increase your chances of winning.
1) Collect all of your paper work together that is relevant to your claim.
- Your policy
- Any relevant medical bills
- Any correspondence you have had with your insurance company regarding the claim
2) Review the denial and prepare your documents.
Review the denial of your claim information provided by your insurance company. Be sure that you understand the reason why the claim has not been paid. It could just be that the staff at your doctor’s office did not supply all of the necessary information that your insurance company requires. In cases like this, it will be much easier to resolve the claim.
Read through the fine print on your policy for any exclusions that may give an indication why your insurance company is disputing your insurance company. You may discover that the medical procedure that is in dispute is mentioned specifically as an exclusion that you were not aware of. In these cases you will probably be out of luck and the insurance company will probably not honor your claim. If the procedure you are claiming is not specifically mentioned or if any of the exclusions that are lated to the procedure are subject to interpretation, then you might have a chance and it may be beneficial to talk to your insurance company.
Before you call your insurance company, go through all of the documents thoroughly and circle or highlight any information you might possibly need when you talk to your insurance representative, including dates, invoice numbers on your medical bills, any correspondence you have that relates to the claim, and any policy exclusions that are relevant.
3) Contact your Insurance Company
Call and speak with a customer service rep or claims adjuster. Explain to the insurance representative that you have thoroughly reviewed your policy as well as supporting documentation, and that you believe that the denial of your insurance claim was an error. Ask them to give you a date as to when your claim will be resolved. Do not hang up until you are provided with the date. Be sure that you get the name of the representative that you are speaking with. If you haven’t heard from them by the date provided to you, call the representative back to follow up.
Be sure to document all phone conversations you have with your insurance company. Include the date and time as well as the conversation’s outcome and name and position of the representative that you spoke with.
4) Consider whether or not to file an appeal
If your insurance claim is not resolved successful, you will need to decide whether or not you will appeal. Each state has their own process for appeals, so you will need to contact your state’s insurance department to find out what you need to do to file a claim.
Most states do have a limited time frame in which you can file an appeal. As an example, in California you have six months to appeal the denial of your claim. In New Mexico 20 working days is the time limit, and Texas does not have a time limit. Since every state has different requirements, you need to find out what your state’s requirements are and get your appeal process started quickly.
