Saturday, June 13, 2009

When Health Insurance Companies Refuse to Pay

Having trouble with your health insurance?

Odds are that you, or somebody you know, have had to fight with a health insurance company recently over medical bills that they refuse to pay.

Like all companies, health insurance firms are for-profit businesses, and every medical claim they fail to honor - despite the high premiums they charge - is yet another chance to put money in their pocket.

So short of hiring a lawyer, what's a patient to do? A lot more than you think, say the experts.

Remember that while individuals may not hold powerful sway over a large company, there's safety in numbers in getting your appeal heard. Here's how to be your own advocate or to enlist help in getting your medical claim paid:
  • If your insurance company refuses to pay a claim on the grounds that a certain procedure is not "medically necessary", read up on evidence related your particular condition. Get letters from your doctors, or gather additional testimony in print or on the Web that support your claim, i.e., with articles from JAMA, or other medical journals to support the effeciveness of your treatment. On your next appeal, pile on the paper.
  • "Sorry, That's A Pre-Existing Condition" - A favorite of insurance claim reviewers, this one is often used as a scatter-shot approach to deny a claim, and any flimsy excuse can be enlisted in trying to enforce it.

    In one recent NY Times article, for example, (
    Getting a Health Policy When You’re Already Sick) a patient was denied treatment of mouth cancer because he was treated for a canker sore six months earlier. The health insurance company later reinstated coverage only after the patient's doctor successfully proved that the two conditions had absolutely nothing to do with each other.
  • Again, you don't have to take no for an answer. Most health insurance companies are betting that you'll get tired of appealing and just give up.

    Luckily for consumers, there's plenty of other assistance available by enlisting the help of your
    state insurance watchdog, or by contacting the Patient Advocate Foundation who do a wonderful job in helping patients push back against health insurance denials.

    Finally, if all else fails, get an attorney involved. There's nothing like a threat from a law firm (or at least a related "cc" to them on all correspondence) to make health insurance companies sit up and take notice.

More about dealing with health insurance companies around the Web: