Fighting Denied Insurance Claims

It’s probably no surprise to you, but insurance companies don’t like paying claims out to their customers. Whether we’re talking about homeowner’s insurance, car insurance, or (especially) health insurance, insurers aren’t eager to open up their wallets to transfer money back into yours. Even when something happens that perfectly fits what the insurance policy is designed to cover, you’ll frequently find your insurance company trying to avoid paying.

In many respects, this makes sense. After all, insurance companies’ profits equal the amount they take in from premiums minus the amount they pay out; if they can increase the former or decrease the latter, their profit will rise. From their perspective, the fewer claims they pay, and the less they pay for each claim, the better.

My Troubles with Insurance

From your perspective, though, that’s the exact opposite of what you want. If you’re making a claim, particularly health insurance claims, it can be tremendously difficult to get the insurance company pay, even when the money is owed to you according to the terms of the insurance policy. Not only are there frequently numerous conditions hiding in the policy, but you’ll find plenty of reinterpretations of just what those terms mean when they mean money should be coming from the insurance company to you (or the people who provide you with health or services), rather than going from you to the insurance company.

When you have paperwork piles like this just with the basics of your insurance policies, it can be overwhelming.

I’m sadly speaking from experience here. If you’re anything of a long-term reader (or simply want to follow this link), you’re probably well aware that I’ve had a few epileptic incidents earlier this year. Luckily, the healthcare system in my area has helped take care of me after my major seizures, and has provided me with medication that greatly limits even the minor incidents. I have little to complain about when it comes to the medical treatment I’ve received.

My insurance coverage, though, that’s a different story altogether. I won’t get into too many details, partially because it’s a fairly long story, partially because I do like to have some privacy, but mainly because I’m not sure how much I should share in situations like this. The short version is this: the insurance company I was using, United Healthcare, has rejected all the payments related to my epilepsy incidents, and insists that I pay all of the medical expenses. (All forty-thousand plus of hospital costs, medical test expenses, and doctor bills.) I’ve been disputing their decision since I’ve gotten the first rejections, but so far, I haven’t seen any changes.

Handling Insurance Rejection

What should you do if you find yourself in a similar situation to mine, with your insurer refusing to pay out your claim (or offering far less than appropriate, given the terms of your insurance policy)? It might take a lot of effort and time to finally get everything settled. But, there are some steps you can take to dispute your claims rejection. Try doing the following, and hopefully you’ll have more success than me in handling these disputes:

1. Read (and Re-Read) Your Policy: You should make a point of doing so before you have any trouble, of course, but the moment you (or someone you love, whom you are handling insurance issues for) run into trouble, it’s good to double-check exactly what your policy covers. The better you understand what your policy does (and does not) cover, the better you will be able to dispute a denial of your claim(s).

2. Be Prepared for the Appeal: You’re going to want to appeal the claim, that is, try to get the insurer to change their opinion on the coverage and pay your claim (or at least some of it). Before you start what can be a rather long process, you’ll want to be sure to get all your ducks in a row. Particularly with health insurance, there can numerous reasons why your insurance policy was rejected, and it might not always be clearly stated on your claim form. If that’s the case, try calling your insurance company to clarify the situation, to make sure you understand why your claim was rejected. Do NOT initiate the appeal process with this call; don’t mention an appeal, but simply find out the needed information (the reason why the claim was rejected, who should be contacted about the appeal, how long you have to appeal, and similar issues).

3. Go Over Their Head: Alright, it might not be ‘going over their head’, per se, but you can have your appeal reviewed by an independent agency in most states. This will give you a chance to have your claim appeal reviewed by someone who doesn’t have a vested interest in your claim being denied. You can find out more information about your state’s rules via the National Association of Insurance Commissioners, as this NY Times article notes. (Side Note: Apparently I’m not the only person who’s had trouble with United Healthcare paying claims; the main subject of this article also a claim rejected by them.)

4. Get Help: With all the power that insurance companies have, you might feel overwhelmed. Luckily, you’re not completely alone in your appeal attempts. There are organizations that help people who suffer from an array of health problems, so a little searching for your diagnosis and insurance help can yield some positive results. Under the new healthcare bill (aka, Obamacare), there are also Consumer Assistance Programs being set up to help consumers file complaints and appeals. Don’t forget about your family; besides being able to provide support and witnesses to your health issues and coverage, you may find family members who can help you file your paperwork. My sister, who worked at an insurance company for a few years, has been helping me to arrange my appeals. And speaking of appeals, plural…

5. Be Prepared for a Lengthy Fight: As I mentioned at the start of this article, insurance companies don’t want to pay out claims; every dollar that goes to a claimant comes from their profits, after all. You can expect at least a little resistance to your claims, sometimes even high levels of resistance. You can expect quite a bit of work to get your appeal filed and even more to get it accepted. ┬áBe ready to file multiple appeals, make your case in multiple ways to multiple organizations, and generally fight like heck to get your claim paid out. It’s not likely to be an easy fight, but if you stick with it, you can get your rightful claims paid out.

These steps should serve you well as you try to appeal a health (or other type of insurance) claim. What advice would you have for insurance claimants who have been denied? Should insurance companies pay out claims more easily (even if it ends up costing them huge amounts of money)? Have you had any difficulties in getting your claims paid by your insurance company?

Picture courtesy of Keith Williamson


Please enter your comment!
Please enter your name here