Health Insurance Claim Denials 101

By: Debbie Sines Crockett, Esquire

www.boylegentilelaw.com

Boyle, Gentile, Leonard & Crockett, P.A.

Often times, consumers accept coverage denials from health insurance companies without question.  While pre-authorizations are not a promise of coverage, consumers and medical professionals rely on them when proceeding with medical treatment.  In these situations, consumers do not even become aware of the health insurance company’s refusal to pay claims until well after having received the medical care.  Suddenly, bills start flooding the insured’s mailbox.  While the idea of fighting an insurance company can be daunting, in many instances, it can well be worth the fight.

After a denial, the first step is to see if the policy contains any appeal provisions.  This means that the policy will allow the insured to ‘appeal’ the denial by allowing an internal review of the denial decision upon the insured’s request.  If the internal review does not overturn the denial, then some policies may allow a second appeal to an outside review board, again upon request.  The timeframes for appeals may be quite strict and are often very short, so it is important to review the policy thoroughly.  It is at this time that the consumer should strongly consider getting an attorney involved to assist in the appeals process, as the policy provisions must be strictly adhered to.  An attorney can assist by both ensuring that the appeal is timely filed as well as by ensuring that the appeal contains the information and documentation required by the policy.

In preparing any appeal, it is important to include copies of medical records as well as a detailed cover letter outlining all the reasons the denial was incorrect and that the treatment should be covered.  The letter should highlight relevant portions of the policy and application.  For instance, if a carrier denies coverage due to a misrepresentation on the application, then direct the reviewer’s attention to the application, itself, while explaining that no misrepresentation occurred.  Often times, medical providers are willing to write letters that support the patient’s position for coverage, including explaining a certain diagnosis or reason for treatment.  Insurance agents/brokers can also be helpful by providing a letter as well.  This is also a good opportunity to point out mistakes made by the carrier.  Consumers should read everything they receive from the carrier carefully.  There have been times when the carrier, itself, has written letters to the insured, citing to incorrect policy language or incorrect policy periods.  If the carrier cannot even get the easy things right, how can the carrier be relied upon to get the more difficult insurance coverage questions right?  The insured should make the most of this opportunity by providing any and all information and documents to the carrier. 

If a second external review appeal is conducted because the first appeal was unsuccessful, the information to be submitted is similar.  However, do not rely on the carrier to forward information to the external review board.  Again, the more diligent, thorough and detailed the submission, the better.  Take the time to submit the information directly to the external review board, along with any additional or supplemental information.  Again, adhering to deadlines identified in the policy is vital to a successful appeal process.

If the health insurance company upholds its denial, then because all administrative type review processes have been exhausted, the next step would be to file the lawsuit. 

When deciding whether suit should be filed, in addition to considering the strengths of the insurance coverage case itself, it is also important to determine issues like whether the policy is an out-of-state group health insurance policy or subject to ERISA. 

The law offices of Boyle, Gentile, Leonard & Crockett, P.A. represent policyholders who experience claim denials of any type of insurance such as life, auto, disability, homeowners’ and health.  As soon as a carrier refuses to pay medical claims, we are available to represent consumers in the appeals process and after.