HEALTH INSURANCE: What to Do if a Health Insurance Company Denies Your Claim
Major illness or a stay in the hospital following an accident can be stressful. It’s
not a time you want to be worried about your insurance coverage. However, for
some insurance consumers, this is when they are hit with a denial – notification
their insurance company won’t pay all or part of a claim.
To help understand your options when a claim is denied, the National
Association of Insurance Commissioners (NAIC) suggests these steps:
Read and Understand Your Policy
Your individual health insurance policy is a legal contract with an insurance
company. It is imperative to read your policy thoroughly to understand your rights
and responsibilities. Your policy will also detail the medical conditions and
benefits for which the insurance company will and will not pay. If any part of the
policy is unclear to you, seek additional clarification from your insurance agent or
If you have further questions, contact your state insurance department. Link to
their Web site by clicking on “NAIC States & Jurisdictions” at www.naic.org.
What to Do if a Claim is Denied During Treatment
Make a list of questions and immediately contact your insurance company. You
will find contact information on the back of your insurance card.
Keep notes of all conversations you have with company representatives. Include
in your notes the name of the person with whom you speak, as well as the date
and time of the conversation. Ask for the person’s phone extension so you can
contact them directly the next time you call. Listen carefully and make note of the
answers given to you by that person.
Stay calm and be positive. It will make the process go more smoothly and could
result in a more beneficial outcome on your behalf.Be Persistent
Keep in mind that a simple error might have caused your claim to be denied. The
hospital or the billing staff at your doctor’s office might have entered an incorrect
code when your claim was filed with the insurance carrier. Or your claim might
have inadvertently been sent to the wrong insurance company. This type of error
can usually be cleared up quickly with a single phone call.
If, after your initial conversation with the company, they are still refuse to pay a
claim, be persistent. While most insurers pay claims presented to them in a
timely manner and in accordance with the wording in their policies, a few carriers
might initially delay or deny the payment of a claim. If this occurs, be sure to
obtain the claim denial in writing. You might need to make several calls to the
company before it pays the claim.
What to Do if an Insurance Carrier Continues to Deny Your Claim
Contact your insurance department for assistance appealing your claim.
Generally, you must first submit a letter to the insurance company requesting that
your claim be reconsidered, giving specific reasons why you believe your claim
should be paid. When composing your letter, be as detailed as possible
explaining why your procedure or medication is necessary and should be paid for
under your insurance policy. Request all evidence (medical records, x-rays, lab
results, etc.) available in support of your claim and send it to the insurance
company with your appeal letter. Be sure to keep a copy of everything you send
to the insurance company for your records. In response to your letter, your
insurance company will indicate the next steps in the process, as well as the time
frame for any additional follow-up or appeals. They may also request additional
information from you and/or your medical providers.