by Scott Blumenshine
An all too familiar scenario is an insurance company that fails to pay a legitimate claim for a customer. Americans pay a large amount of money each month to be able to afford the medical care they need. Out of control medical costs are driving insurance companies to have an outright denial policy for every claim unless the customer fights tooth and nail. Most people have experienced this outrageous behavior by insurance companies at least once in their lifetime. When an insurance company fails to pay your claim, it is not the end of the road. You have options to appeal the decision and it is crucial that you understand your rights so you can fight to have the coverage you deserve.
What do I do if my insurance company fails to pay my claim?
Especially for larger claims, many insurance companies will have a “deny first” policy. This entails sending a letter to the customer that informs them that their claim has been deemed “not medically necessary” for purposes of coverage under their plan. This happens despite their doctor’s orders. They will direct the customer to file an appeal, which includes gathering a significant amount of paperwork and writing a detailed declaration including the details of the claim. There is typically a term of 60-90 days in which the appeal is reviewed and a decision is given.
First Appeal Denial
After a first appeal has been denied, the insurance company hopes that you will give up and pay the claim yourself. Sadly, many people lack the resources, time, or knowledge to continue the fight. After a denial, you should seek the assistance of an experienced attorney. Hiring an attorney who understands the insurance system and how to effectively argue your case makes all the difference.
Second Appeal Denial
Second appeals may still be denied even with a legitimate claim. Under the Affordable Care Act, insurers are required to have an external review process. The review panel is chosen by the parties and must be part of an independent review organization with adequate training in medical procedures. Generally, the insurance company will be forced to pay legitimate claims at this point. This process is extremely time consuming and expensive, and the insurance companies are betting on the majority of customers to not follow through with the complex process.
What are the insurance companies required to tell me about my denial?
When you pay for an insurance plan, you have the right to certain information about your claim and coverage. The Affordable Care Act aimed to help bring more transparency between customers and insurance companies. It is important when you have a large claim that you clearly understand your rights to certain information. Insurers are required to tell you:
If you have already been through the appeal process and your claim has been denied, it is important that you take action to assert your rights. Speaking to an experienced attorney is the first step in showing the insurance company that you aren’t backing down. Your attorney will act as a legal advocate and is required to look out for your best interests. An attorney also helps to explain the complex process and create a legal strategy based on their knowledge and experience in dealing with insurance companies. There are certain time limitations when it comes to the appeal process, so it is crucial that you act sooner rather than later. Otherwise, you run the risk of not receiving adequate coverage on your claim.
We have all heard about cases where an insurance company refused to pay a claim by a customer, especially with the massive amount of information on the internet. Friends, siblings, parents, and other family, as well as just people that we might only know online – you can think of someone that has had problems with an insurance company on a claim. So what happens when an insurance company refuses to pay a claim? How do we keep an eye on these insurance companies and hold them accountable when they do not hold up their part of the contract?
Here is a great article that focuses on keeping insurance companies honest when it comes to paying claims that everyone should read: