If I Lose My Health Claim Appeal
What should I do if I can't get my health insurer's decision reversed?
You have several different means. You can go through the appeal process and if you are not successful there, it's going to depend on how important the procedure is, or the dollar value of the procedure that is denied. If you want to get that medical procedure covered one way or another. You might have to go into your own savings to get it done. You don't want to wait for payment and delay your best health care. On other issues, you can go ahead and enlist a health care specialist or a lawyer, but that does tend to be expensive and you should only do that in the most expensive and the most urgent situations.
Can the government help me get my health insurer's decision reversed?
The government can help you. Most states, in a managed care context have ‘Departments of Managed Care,' because there have been so many outrageous denials by HMOs. Most state governments have a ‘Department of Insurance' - a general place that will help you against traditional insurance companies if you have a dispute. Generally, what you do is get on the phone and talk to the Department of Insurance in your state - they have different representatives - and you explain to them what you need. You will explain to them the time frame, and the name of the company and what the company is. They will then file the complaints or sometimes act as an advocate for you with that company or they'll tell you outright that, ‘Well, they have that contract and they can do that,' and, ‘Sorry, we can't help you.'
Can anyone inside a health insurance company help reverse a decision?
"Inside the insurance company" and "help you reverse a decision" are oxymorons. They're there to limit the amount of care, they're there to maximize their profits, and they're there to put profits over people. However, if you're going to call inside the HMO, it is important to get past the initial 1-800 person who answers your call. You should request to talk to the medical director. You should always request to talk to a supervisor, and you should ultimately request to talk to the legal department, because every medical HMO type large organization has a legal department. With a PPO too, you want to go to the highest level possible. If you're writing to them, you want to write to the CEO. If you're phoning them, you want to get the medical director. That is the guy that's going to make the most important medical decisions and oversee the decisions that are made. You want to get to the legal department if you feel qualified to talk to those people about something that should be covered. You've need to remember all those people are going to want you to talk to the 1-800 person and work your way up to them, but you want to start with those type of people if it's an urgent, important enough thing that makes you want to call them.
What steps can I take to fight my health insurance company?
To fight the insurance company once you have a denial, you should write them directly to the CEO, in a FedEx, outlining why you need it, who you are, and give them a time frame to make their decision. You should also contact the medical director or the legal department to make yourself aware, on their radar screen, to know that you're aggressive and you're coming after them. If it's a large dollar item and/or a very important item that your health depends on, then you have to consider possibly seeking out a governmental entity regulatory department, such as the Department of Managed Care in your state Department of Insurance. Also, depending on the dollar value and ability, you should seek out legal assistance at some point, if it feels that you're getting nowhere through the other means. But most people don't even know to start calling at the medical director level, at the legal department level, or at the C.E.O. level and sometimes that can help you a long ways down the line without the need of a lawyer.
What kind of professional help can get my health insurer's decision reversed?
The first line of help is by using your doctor to help you, and by using your broker to assist you and advocating what you need. The broker was involved in getting you attached with this insurance company, and he or she should earn their money by helping you. You can also use the state government agencies, Department of Insurance, Department of Managed Care, and as a last resort you can use a lawyer. It's important to ask that lawyer some questions: Do they have experience in battling HMOs insurance companies? Do they have specific experience in the procedure you're denied? The legal industry has got so specialized, that there are now people who specialize in certain procedures, or certain companies. Therefore you want the person most specialized to your requirements. You don't want someone practicing literally law on your case.
When should I hire a professional to fight my health insurer?
If you can't afford to wait to deal with your HMO, if you can't afford the procedure at issue, or if your life is at issue, that's when you might need to go - if your doctor hasn't been able to help you - to a lawyer. There's injunctions that can be brought, where we can enjoin, or stop, a company from the denial of payment, and force them to pay for your care if it's medically necessary, if it's urgent, and if we can show them that you might die without this procedure.
How do I find an attorney to help fight my health insurance company?
You can type in 'HMOs' and 'verdicts' on the Internet and see what would turn up. You can call county bar associations. You can call the finance department at major university hospitals, because they're usually aware of the people who are at the highest level who have battled for their own patients and battled successfully. It's important to find someone who has been down the road before, who has a track record and that the insurance companies are aware of. They need to know that your advocate will go the distance and that your advocate has had success. It is also important to find someone who has dealt with the media, because all of these publicly owned and quarterly profit-driven companies fear attention. If you have the right type of case that will get attention, sometimes the right attorney can handle that much better than others. Sometimes that can get you coverage long before your insurance contract will.
How much should I expect to pay an attorney to fight my health insurer?
It depends if your case can be taken on a contingency basis. This means that they get a percentage of what you get in the end or if it's an hourly type of case. So, the ranges will vary, but, again the best help is what you want to seek out and then consider the cost later. There is a lot of people that do probono work for people that need four or five letters that need some type of adversity in the situation. And, so that's one thing to ask, would they be willing to help you out, in any level, at no cost.
How do I know if I have a contingency case?
In fighting health insurance companies, we discussed ERISA earlier, and if you are denied by a health insurance company and you are a public employee, a church worker, or you write your own check to the insurance company, you have the ability to sue an insurance company for more than the dollar value of the treatment denied. So if you fall into those categories there is a good chance you will find someone who will take your case on a contingency basis, meaning you don't pay anything unless the lawyer is successful, because that lawyer in those cases has so many more weapons to use against the bad health insurance company trying to get you care. If you get your health insurance from a private employer, there has been a moat put around these health insurance agencies and they basically can keep you from going to court against them. In those cases, usually you are going to have to pay hourly for an attorney to battle those cases because if you spend two years on this case, the most you can ever get back from the robber is the amount of money he stole from you. That person doesn't have to do any jail time, there are no extra benefits financially to be paid.
Will ERISA restrictions be changed so that I may have a contingency case?
The ERISA law that limits you, if you are denied, to the dollar value of your procedure, not to the harm cost by the denial, is trying to be reversed on many fronts. But the health insurance industry has more money than the lawyers, the doctors or the average person. Uniquely, the lawyers and the doctors are united to try and take this on because it is an unfair thing. And if there is ability for accountability up front with these health care insurance companies we know that they are going to pay more rapidly and they are going to eliminate the need for lawsuits. However, the health insurance has been very successful to say that any changes in this law is a lawyer get rich bill, as opposed to something that would be a preventative measure. They have, with their lobbyist, really limited that ability for anyone to change that law once it is in place.
What are the costs associated with fighting a health insurance company?
Well, there's the human cost, for each individual, and that's why it's only as a last resort that we file the lawsuit. With each lawsuit, there's a human cost of someone involved and having that hanging over their head. Usually those costs are much smaller than the costs of doing nothing, so we have to evaluate, and with some clients, we'll just tell them that this is not enough to fight over, or we don't think you should, for your health reasons, take on this insurance company. There are various reasons we do not recommend fighting a health insurance company; these can include health, emotional, physical and financial costs associated with a lawsuit, and again, we stress that a lawsuit is the last resort. We try to get in there and work with the insurance companies based on our reputation and background, and to get the problem resolved before you have to sue.
Will my health care be affected if I fight my health insurance company?
You should talk to your doctor's front office, or the university hospital's front office, or the surgical office and say that if the health insurance company don't come through, what is the minimum amount you have to pay to get the procedure started? In many cases of treating patients with cancer, there are cycles of chemotherapy, cycles of treatment. It spreads out over many months. What's it going to cost to get you started on the road to recovery, on the road to the cure that your doctor's recommended? That's an important question to ask so that you can, through a home equity loan, through family and friends, or even through fundraisers, try to come up with the amount of money while the health insurance company is in the process of denial.
What documentation should I get when fighting my health insurance company?
The denial language. You want to force the insurance company to put in writing why they're not paying for this. Or, if there's some specialist or medical doctor involved, you want to find out who those people are who are behind the denial. Also get information on who is deciding that you don't get the care? We had a case of an anorexic who was denied by a former eye surgeon in deposition. He had no background on anorexia, no one in his family had it, and none of his eye patients came to him for anorexia. So it was very important to find out in that case that the person denying the treatment had no background in the treatment and was really just an internal hired gun to save the company money.