No one can anticipate becoming seriously ill or injured, but we can prepare for the possibility of such a situation by carrying health insurance. Medical care can be prohibitively expensive, and we rely on the insurance we have been paying into to help us pay our bills in our time of need. So, if your health insurer denies your claim you will want to consider filing an internal appeal or pursuing an external review.
Internal appeals
In an internal appeal, you ask your insurer to review its decision in a timely manner. If your insurer is denying your claim, they must provide you with written notice explaining their decision either within 15 days of prior authorization, within 30 days for care already received or within 72 hours in an emergency. You will have to complete forms provided by your insurer or you can write to your insurer and provide them with your identifying information. You can also submit supporting information, such as a physician’s letter. An internal appeal must be filed within six months of the denial. The insurer has 60 days to complete an internal appeal for services already rendered or 30 days for services not yet rendered.
External review
Depending on the situation, you may opt to pursue an external review by a third party. To do so you must file a request for review in writing within four months of the denial. The external reviewer will either side with your insurer or issue a decision in your favor. Denials involving medical judgment, denials claiming the treatment is experimental and cancellation of benefits on the grounds that you provide false or incomplete information when you applied for coverage are three types of denials that may qualify for external review. External reviews must be completed with 45 days of the request for review. Expedited external reviews can also be sought in emergencies.
Your health insurance company has the duty to act in your best interests. If you are denied the benefits you paid into you may have the legal right to pursue an internal appeal or external review. You deserve to be compensated appropriately per your policy and you deserve to be compensated for any economic damages you are due.