What to Look for In Your Health Insurance Policy, Part 1: Does Your Policy Provide Benefits for Out-of-Network or Out-of-State Benefits?

The internet provides patients with the resources to locate healthcare providers anywhere in the world. But whether your health insurance pay benefits for treatment with a health care provider anywhere in the world is another issue. Patients are often unhappily surprised when they discover that their health insurance policy limits them to healthcare only within their state or within the health insurance company’s network of providers.

The first step to understanding your health insurance coverage is requesting a copy of the policy. The policy dictates your healthcare coverage. Review your policy to learn whether your policy provides benefits if you go out of state, or out of the country, or see an out-of-network provider for treatment.

If the policy limits you to in-network or in-state benefits and you find a healthcare provider that is perfect for your needs, don’t lose hope. If you can show that there is no in-network or in-state health provider appropriate to treat you, you have a good argument for asking for out-of-network or out-of-state coverage even if the policy only approves in-network or in-state providers. The best argument will demonstrate that there are no in-network providers willing to take new patients or it is outside of their area of expertise. This argument will require through research through many telephone calls to in-network providers to determine whether they will accept the patient. Similarly with out-of-state providers, the argument requires research to demonstrate that there are no in-state providers available.

Policy language limiting coverage in-network or in-state cannot be challenged simply because the patient prefers an out-of-network or out-of-state provider better than in-network or in-state providers. There needs to be a documented and specific healthcare need that cannot be met through an in-network or in-state provider. Once the research is gathered, it should be submitted in a hard letter sent by confirmed mail to the insurance company. Telephone calls cannot substitute for a written letter. While not easy, these claims are not impossible if backed with through research about the limitations of the in-network or in-state healthcare providers.

If you’ve found yourself or loved one in a situation like described above, please contact Kantor & Kantor at 888-569-6013 or use our online contact form for a free consultation.

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