::::::::::::: Personal Finance :::::::::::::
The Claim Game
It happens 500,000 times a day: an insurance company denies a health claim.
Here’s how to fight back when your insurer says no By CAROLINE E. MAYER
Every time Milton Hillery, 76, gets a letter from his health
insurer, he worries: Has my claim been rejected again? Is this
another questionnaire asking if I have other coverage?
“I fill out the questionnaire, send
it back, and three weeks later I get
another one,” says the retired Maine
educator, who pays for a private plan
to supplement his Medicare coverage.
“You can call the company and say,
‘I’ve responded,’ and you’re politely
told it’s not in the records, but they’ll
take care of it. Weeks later you get the
same questionnaire. It’s pretty clear to
me, delaying payment is their intent.”
For Hillery—who has diabetes,
among other conditions—tussling
with his insurer is an annoyance. For
Arizona resident Theresa Rattei, it
became a life-and-death struggle.
Rattei, 51, was diagnosed with a rare
cancer in 2006 and had chemotherapy
twice, with little success. In January
2008 her doctor prescribed a radiation treatment, but the insurer managing Rattei’s health plan deemed it
experimental—and thus not covered.
The problem: Her cancer was in a
bile duct just outside the liver. Had it
been in the liver, the treatment would
have been approved. The difference is
“a matter of millimeters,” says Rattei.
Margie Griffin of the Patient Ad-
vocate Foundation (800-532-5274;
patientadvocate.org) helped Rattei ap-
peal to her husband’s employer—em-
ployers being the real payers of claims
under what are called self-funded
plans. It took eight months of battling
to win approval of the treatment as a
medical necessity, and the radiation
did halt the cancer’s advance for a
while. Though now, Rattei reports,
“two spots have grown in my lungs.”
The debate over health care reform
may revolve around the uninsured, yet
even for Americans with insurance,