Just about everyone knows that our healthcare system is enormously complex. Insurance plays a big part in that. Yet, most people are comforted knowing that they have insurance coverage, expecting that it will kick in when needed. The sad truth, though, is that many health insurance companies either refuse to fully pay policyholders’ claims or simply outright deny them. This can leave patients in a challenging financial position with limited treatment options moving forward.
This is unacceptable, which is why if you find yourself in this position you need to consider how to appeal the denial of your claim. Under the law, there are two ways to do this. The first is an internal review of your claim. Here, you timely submit documentation and your insurance company internally reviews the denial, issuing a decision within 30 to 60 days depending on whether you’ve already received the services in question. This might not seem like a fair way to handle an appeal since the determination comes from inside the insurance company that already denied your claim, but some success can be achieved through this route if you have evidence that addresses the reason for denial.
If your claim is still denied after an internal review, then you can seek external review. Here, your insurance provider is required to allow a third-party to review the claim and render a decision. That decision is then binding on the insurance company.
If this all fails and you think that your insurance company has acted in bad faith, then you can take the matter to court. The legal system is pretty receptive to these kinds of cases, oftentimes awarding punitive damages that provide significant financial relief while punishing insurance companies who fail to act in your interests.
Your insurance claim can be denied for a number of reasons. Your insurer might allege that your plan doesn’t cover the condition or treatment in question, that your injury predates your coverage, that there’s insufficient evidence showing medical necessity, or that the claim was filed too late. Regardless of why your claim was denied, you need to know how to fight for the coverage you need and expect. With the assistance of a legal advocate who is experienced in this realm, you can better position yourself to present the evidence needed to maximize your chances of successfully appealing your denied claim.