Challenge # 1: Understanding your policy
Navigating through your policy, or simply sifting through documents from
your insurance company, can be very tedious -- and even more so when you
do not understand the "language." Becoming familiar with your
policy can help you understand commonly used insurance terms and strengthen
your proficiency when communicating with insurance companies. Before you
can begin advocating for the health benefits that you are entitled to,
you must have a copy of your insurance policy. Ask your employer or insurance
company to send you a Summary Plan Description and all Benefit Plans provided
by your employer. You should know that upon written request, your employer
(or the Plan Administrator) is obligated under Federal Law to provide
you with information regarding benefit programs within 30 days. Know your
policy: without it, you don't know the rules!
Plenty of people have difficulty interpreting the terms of their policy.
It is not uncommon for our clients to seek our advice in making a claim
or appeal to their insurance company.
Challenge # 2: Communicating with insurance companies
Better Homes and Gardens (BHG) conducted a survey of over 1,000 women across
the country. They found many survey respondents to be intimidated simply
by the thought of contacting their insurers. 44% of these participants
confessed they lacked confidence in communicating effectively with insurance
companies, and 76% said they desired to learn how to properly communicate
with their insurer. At
Kantor & Kantor, LLP, we understand how challenging and overwhelming the prospect of trying
to get answers from your insurance company can be. We advise that you
try to stay off the phone as much as possible! All communication should
be in writing, in traceable forms such as certified mail, fax or e-mail.
If you can't prove it, it never happened! Although it's not always
possible, while you are on the phone try to get the name, title, phone
number and email address of everyone you talk to. Speaking with different
insurance representatives can become confusing and overwhelming. Keep
a journal of your conversations so that you can refer back to them later.
Challenge # 3: Filing Appeals when coverage is denied
30 % of the BHG survey participants reported that they have been billed
for something that they believed should have been covered. Sadly, many
people who fall into this category end up paying the insurance company
without a fight. For instance, 57% of participants said that they would
not know how to appeal a coverage denial, and 23% of participants said
that they have actually ducked the appeal process because it seemed too
complicated. The appeal process is complicated, but it is often worth
the effort! Former Insurance Executive Lisa Zamosky (author of Healthcare,
Insurance, and You) said that more than half of all appeals are decided
in the insured's favor. Below are a few simple tips to help make you
more familiar and comfortable with the appeal process, in the event that
your health insurance claim is unfairly denied. Our hope is that having
this information readily available to consumers will make the appeal process
seem a little less complicated, and a little bit more approachable and
1. The Process
Before initiating the appeal process, request your claim file and policy
from your insurance carrier or employer. You will need to review your
policy. Consider what evidence you have to prove that this coverage is
medically necessary, and include this in your appeal packet. Remember
that if you have an
ERISA (Employee Retirement Income Security Act) governed policy, once a decision
is made on your final appeal, your file is closed. Any information you
leave out may never be heard or considered by a court!
2. Your Policy
"Your policy is a contract," says Cofounder of Health Advocate
Martin Rosen. "The more you know, the better case you can make."
If you need help interpreting the language of your policy, do not hesitate
to contact an expert.
Kantor & Kantor, LLP offers no-cost consultations, and can offer support when appealing a health,
disability, or long term care insurance denial.
3. How To Write An Appeal Letter
Your appeal letter should read like a cover letter to your insurance company.
Refer to the evidence and documents enclosed in your appeal packet, and
indicate why this information should change their mind. Although appeal
letters vary in style, the format of your letter should include the following:
First, simply state that you are appealing the decision. Next, explain
why you disagree with the decision. Finally, provide support to your claim.
Take this opportunity to explain the history of your health condition
and treatment, including side effects of any medications, and the full
impact the illness has had on your life. In your letter, consider including:
-Summarize any prior letters or documents
-Point out the inconsistencies in your insurer's decision
-Point out the irregularities in your insurer's decision
-Point out the omissions in your insurer's decision
-Enclose any new documents
4. Gather and Include Evidence
Include copies of all medical records. Remember to keep copies of all out-of-pocket
expenses for future reimbursement.
5. Get Written Support From Your Doctor, Family, and Friends, and Co-Workers
Letters from providers and family members can be a powerful way to display
how your illness has impacted your life. Be as thorough as possible so
that you can transmit the full picture to the insurance company.
6. Understand That A Denial Is Not The Final Word
A denial by your insurance company is not the final word. With a little
advocacy, research, and determination, you will have the tools to fight
for the health benefits to which you are entitled. For some, it might
be possible to overturn a denial without legal assistance. If a case becomes
too complex to manage on your own, you may want to consider seeking assistance
from a reputable professional.
Kantor & Kantor, LLP is one of the most experienced and highly respected law firms dealing
with the prosecution of claims against insurance companies. We represent
clients whose insurance companies have failed or refused to pay claims
arising out of Disability, Health, Life, Long Term Care and other liability
insurance claims. If you, or anyone you know has questions about claims
against their insurance company, contact us for a free consultation at
(888) 569-6013or visit us at
Kantor & Kantor, LLP. We can help.