Fighting My Health Insurance Company - Secrets

Is health insurance a scam?

Some insurance companies try to do it right. Most cases that we get involved in, it does seem as if there's a real scam. It's got a huge need, a significant need, and a costly need. It might make a difference of life or death, and yet they take some ambiguous clause in trying to force your procedure into that clause. Whether it's not medically necessary, investigative, experimental, or meaningless terms for purposes of limiting the cost of care at the expense of lives. And so in many instances, the contract can be looked at as somewhat of a scam.

What is my best defense against bad faith on the part of a PPO or HMO?

Your best defense is to find a doctor who will advocate that they recommended this, and that this is important, urgent, and necessary. The other thing, as an individual, is to be relentless. You're not in the best position to be relentless when you're ill, so find a family member to fight on your behalf through letters, through phone calls, and through faxes. It goes a long way. Usually, people don't have a lot of fight in them at that time, and this even includes family members of someone who's seriously ill.

Is there such thing as 'too much' when fighting a health insurance company?

If it's a life and death issue, there isn't anything against the insurance company that is too much, as long as you're taking legal actions and bombarding them with as much documentation and attention. Sometimes, it's about educating someone because the denial has come at such a low level in the insurance company. It has to get it to the right person. You have to get your information before a decision maker and you have to argue your case. Again, we're least equipped to do that when we're ill. You have to enlist the help of family and friends, and if necessary a lawyer to make your case to the highest level of the insurance company, because they are going to look at the people that are making the most noise. They're going to look at the people who could cost them the most money if they make a mistake.

Who is most vulnerable to bad faith on the part of the health insurance companies?

In taking on an insurance company, the squeaky wheel gets the grease. You've got to be prepared to never give up. Timid people are the ones the insurance companies make millions and billions of dollars on each year. The people who aren't willing to fight. The people who come to the conclusion, it's better for me to just go off and die because I might not win this battle. We've seen a lot of those people. The insurance companies win every time one of those sick people die who other wise could be cured, or could be rescued from their disease. The important thing is to enlist a team of good helpers, advisors and encouragers when you're battling your insurance company and that may include a lawyer.

Why do contracts with health insurance companies seem unenforceable?

Only the contract is enforceable, and, again, because you're dealing with a large insurance company; time and money is on their side. If you're the individual who is sick or dying, and in need of a procedure, you have neither time, nor money. So the insurance company, if they are limited to just the amount of damages or just the cost of the procedure--even an expensive procedure--and not the cost of the death of that person, meaning their lost earnings, the pain and suffering you impose on a family of four that loses their mom or dad, they put it into a cost-risk benefit analysis, and figure, "You know what? We can deny a hundred of these, for the one we might have to pay for." There's a financial cost-effectiveness to denying care that is mixed into this because of the laws that protect HMOs and protect insurance companies.

What's your best advice for fighting a health insurance company?

Write a letter. I don't care if it's hand written, but writing a letter really makes the difference. Also, make a phone call and get others to make phone calls on your behalf. Storing up the inside of an HMO is not that hard to do in raising your case, level, and name to a high level within the company. This is not hard to do, but so many people just want to give up and walk off without the treatment they deserve.

What should I not do when fighting my health insurance company?

When an insurance company denies you something and you're writing a self-help letter to try to convince them, don't ever adapt their terms. If they're trying to label your procedure "experimental", don't write "I'm calling you regarding my experimental procedure." Don't ever accept their false labels that they're trying to couch over your treatment, because anything you write can sometimes be used against you. Also, make sure that you don't accept their arguments. Sometimes you will only have to deal with their arguments. Deal with your own arguments. Tell them why it's medically necessary. Tell them why it is cost-effective. Just because they list three reasons they don't want to approve it, you can still go on the offensive. Generally, you have to couch your treatment as medically necessary and then if you can also say why it's more cost-effective, that's one that always sells within these companies. "It's more cost-effective to go one visit to this expensive specialist and get my treatment covered versus going to your two cheap guys that honestly do not have a background in my procedure, in my need or in my medical condition." If you can argue a cost-effectiveness combined with medical necessity, that's the key.

What should I not do when appealing a decision by my PPO or HMO?

In the review process to your PPO or HMO, you want to make sure again you don't adapt the terms they're trying to deny you by. So you don't want to tell them it's a psychological disease when in fact anorexia has a medical component, too. You don't want to say it's experimental when you don't even understand what their definition is and you may not be having an insurance language experimental procedure. So you just have to be careful to not use their terms and use the broad brush that they have to describe your own individual situation. You also have to be determined to not show them you're willing to go away. So many people call and say, "I'm sure you don't want to pay for this and you're not going to pay for this, but would you think about paying for this?" Right away that shows that you're weak, that you're willing to give up and they're going to say no. So you have to be poised in showing the insurance company you're willing to fight to your death for the procedure if it's that important. In the review process it's real important to say, "My doctor recommends this. My doctor says this.", because you have to remember you are not the medical expert. Don't allow the insurance company to make you a medical expert, asking you to define terms and requests. So the best approach to take with the insurance company in a review process is to use the doctor's language, "My doctor has recommended this. You gave me this doctor. You paid for this doctor. I'm trying to follow your doctor's advice." So make your own doctor their doctor, and that really can help your arguments. But try not to be turned into, even if you have some medical background, try not to be turned into a neurosurgeon. Try not to be turned into a world renowned cancer expert, because you're just following the advice of well-schooled experts. Don't let your PPO or HMO try to define terms with you and against you or label you.