“Don’t take a health insurer’s rejection as the final word on your medical claim,” writes Tom Murphy of the Associated Press in a recent article about how to craft an appeal to an insurance company to re-evaluate a denial. See “Fighting an Insurance Claim Denial Can Pay Off,” http://www.philly.com/philly/business/personal_finance/20110405_ap_fightinganinsuranceclaimdenialcanpayoff.html?page=1&c=y.
Murphy cites a recent report from the Government Accountability Office that found – in some states – appeals have about a 50 percent success rate. The article lists a number of actions policyholders can take to provide relevant information that could prompt an insurer to change its mind. Those factors include obtaining and submitting copies of your entire medical file; enlisting your doctor to write letters explaining the need for medical care; understanding policy language and complying with all deadlines; and supplying medical literature and scientific studies that support the efficacy of the requested treatment.
That’s all good advice, but what the article fails to mention is the impact of federal law on the appeal. Any information not included in this appeal, which is mandatory before you can file a lawsuit against the insurance company for benefits, usually cannot be introduced in the subsequent lawsuit. Don’t just assume you are right and that the insurance company will change their mind. As you can see, at least 50% of the time, they don’t. You must be complete and thorough with what you include in the appeal, because you won’t get a second chance. So… do it right the first time.
If you plan to appeal an insurance denial, we can help. Call us at (800) 446-7529.