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coverage often falls short. Medical debt caused a staggering 62 percent of personal-bankruptcy filings in 2007—and
three-quarters of these filers had some health coverage.
And as congressional hearings in June showed, some insurers revoke the policies of their costliest customers—the
seriously ill.
“Don’t
accept the
company’s
word as final.
It is not.”
Caroline E. Mayer covers consumer issues from Virginia.
For black-and-white reprints of this article call 866-888-3723.
TO MAKE INSURERS PAY
1. Don’t pay the bill.
2. Get a reason for the denial in writing.
3. Review and follow your plan’s rules.
When your claim is denied...
...Make the easy fixes...
• Missing information? Fill it in.
• Coding mistake? Have your doctor fix it.
Health care reformers want to
end these exceptions, but for
now they are hard to overcome:
• Preexisting condition
• Lifetime-benefit cap
• Change of employer, so
coverage was delayed
... And assess other reasons for the denial.
These may be worth challenging:
• No network facility or
physician was available
• Drug wasn’t FDA-approved for your illness
• Treatment was deemed
unnecessary or unproven
1. Check the back of your denial notice to see how long you have
to file—it’s usually 180 days.
2. Gather objective evidence of medical necessity, such as test
results and prior failed treatments.
3. Gather journal articles showing the treatment is safe, effective.
4. File the request in writing (certified mail, return receipt).
When preparing an appeal…
• A nonprofit patient advocate (your state’s insurance
regulator or a disease association can suggest names)
• A lawyer if there’s a large sum of money at stake and you
might end up in court.
If you want help, seek out...
seek an independent review...
If your insurer stands firm, you can
If yours is a fully insured plan—that is, the insurer pays the
claims. (Though insurers administer all kinds of health
plans, roughly half are self-funded, meaning your employer
pays the claims.) You have a fully insured policy if you buy
insurance on your own.
;To appeal a final
rejection by a
fully insured plan...
Go to your state
insurance regulator.
;To appeal a final
rejection by a
self-funded plan...
You will likely need to go to
court, though your state insurance regulator can sometimes jawbone on your behalf.
