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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 manageable.

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.  We can help.