Original content from | Commercial Services | Talent Partnerships
Your epoints

How do I file a health insurance claim?

Using Health Insurance

Elliot Matloff (President and Broker, The Matloff Company) gives expert video advice on: What do I do if my claim is rejected or partially rejected?; What do I do if my doctor recommends a medication or treatment that my health insurance company does not cover? and more...

What do I do if my claim is rejected or partially rejected?

The first thing to do always is to contact your insurance broker. He or she is going to give you a good idea of how to get this problem solved and usually it's not that difficult to solve. It's usually that the doctor hasn't submitted something properly to the insurance company and that's why the claim didn't get paid, or you didn't pay a premium on time. Until you pay that premium on time, the insurance company will not issue a check to that doctor or that hospital. Once this issue is reconciled, the insurance company will prorate the claim and pay everything just perfectly. If you're denied a claim and you still feel you're not getting adequate treatment by the insurance company or the insurance agent, then I would highly recommend contacting the insurance commissioner and filing a complaint, and if necessary hire an attourney to act on your behalf. If you're talking about a forty or fifty thousand dollar claim, you might have to get an attourney, because that's obviously a lot of money. If it's a five hundred dollar or three hundred dollar issue, you might not want to waste your time.

What is a "medical log", and should I keep one?

A medical log is a good idea if you have a lot of conditions or if you need to find a doctor's name or address at a later date. For example, you might apply to a new health insurance or life insurance company, and the agent or broker might ask you what the name of that doctor was that treated you five years ago. So having that information may be very helpful because the insurance company is going to probably want that information and it will save you a lot of time and trouble. I highly recommend a log for your medical expenses and claims.

What do I do if my health insurance company drops me?

It's very rare that an insurance company drops a client. If they see that you've misled them on the application, and that you were not forthright on the application, they obviously could rescind your policy. But don't forget, insurance companies have very deep pockets. If they drop your insurance and they don't have good justification, they will be sued and they will lose a lot of money. So, it has to be something really important for them to drop you. Most health insurance policies are non-cancelable, which means that the insurance company can't cancel you in general unless there's really good cause. If you don't pay the premium on time, they can drop you. If you have lied on the application, they can drop you. But, other than that, I haven't heard of too many companies ever dropping a person on a health insurance policy.

What do I do if my doctor recommends a medication or treatment that my health insurance company does not cover?

If the insurance company does not pay for a treatment or a medication and they say it's not covered under the policy, you have to first of all talk to your agent to find out if that's really the case. If the doctor is recommending something that's not FDA approved, no insurance company in America is going to pay for it. If you decide still to have the procedure done, or if you decide to pay for some special medication it's going to be out of your own pocket, then that's just the way the policy works and there really isn't too much you can do. I'd always double-check with a good insurance broker though because what you think may not be covered may be covered. One reason how this could have occured would be that it wasn't just written up properly when the claim was sent to the insurance company.

What are my recourses if I feel that my health insurance company is treating me unfairly?

Well the first thing is you can decide if you want to contact the insurance broker and see if he or she can rectify the situation. If the agent or the broker cannot help you, then you can go to an insurance commissioner or go through an appeals process with the insurance company. They might change their mind. Because I've had several clients in the past who had problems collecting on a claim and the insurance companies when they finally opened their mind to see that the technique or the procedure that the doctor did was very beneficial for the person, they sometimes come through and pay for the claim. It takes a little bit of hard work and that's what an agent does to earn his commission. Occasionally you will have the situation where you're just not going to get a claim paid because it's not covered, and you have to decide whether or not you're going to hire an attorney or go through that type of expense. Unless you have a real legitimate claim against an insurance company, even an attorney won't handle your case.

Will my health insurance cover me if I go to the doctor or a hospital in another country?

All health insurance policies cover you for any type of medical issue that you have in another country. What you would want to do is, if you gave birth to a baby or had an injury for example, collate the bills, bring them back to the States, and submit them to the insurance company when you got back. If it's a major claim, the hospital or doctor's office in that country would notify your insurers and get permission for procedures then everything would be paid just as normal.The one exception to this is people over 65 with an issue. People over 65 have medicare, and medicare does not cover medical expenses or treatment outside the United States. Therefore a medicare supplement is very important because medicare supplements cover at least $5, of medical expenses outside the country.For people who extensively travel outside the U.S., there are Lloyds of London policies that provide supplemental coverage to the supplemental policy. I highly recommend those.