How to Get Your Healthcare Insurer to Say Yes When They’ve Already Said No

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Jeffrey Johnson is a legal writer with a focus on personal injury. He has worked on personal injury and sovereign immunity litigation in addition to experience in family, estate, and criminal law. He earned a J.D. from the University of Baltimore and has worked in legal offices and non-profits in Maryland, Texas, and North Carolina. He has also earned an MFA in screenwriting from Chapman Univer...

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UPDATED: Feb 9, 2020

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Most of us know what it feels like to have our health care insurer deny our claim. It’s frustrating, if not downright maddening. So, how can you get your health care insurer to say yes to claim when they’ve already said no?

True stories

According to the September 25th issue of Healthy Consumer published in the Wall Street Journal, these consumers were able to change their insurance company’s initial claim denial. Here are their true stories:

  • Murielle Curcio. This 51 year-old Californian was insured with Blue Shield of California. She requested Blue Shield to pay for a breast cancer test, but her request was denied merely because the insurer didn’t have all of the required information – although she didn’t know that at first. Curcio, working with her employer and doctor, provided the insurer with everything it needed and took the process a step further by showing Blue Shield its own policy language that would have allowed for the test and that she was medically appropriate candidate. In the end, the insurer reversed its decision and paid for her test.
  • David Foglesong. This 49 year-old New Jersey man and his wife were insured with Horizon Blue Cross Blue Shield of New Jersey. He requested that the insurer pay for a targeted chemotherapy treatment for his wife, but his request was denied because the treatment was thought to be experimental. Foglesong, working with his wife’s oncologist, consumer advocate groups and doing research on his own, was able to show that the treatment he and his wife were requesting had actually helped others so that its experimental classification really wasn’t accurate. Once Horizon received this information, it paid for the treatment.
  • Sharon Hines. This 52 year-old Connecticut woman was insured with ConnectiCare. She requested that insurer pay for an expensive cancer drug that would have cost $100,000 per year. ConnectiCare denied her request saying that the drug was not likely to work due to the previous medications she had taken. Hines sought the advice of an independent oncologist who agreed with her position and convinced ConnectiCare to change its decision and provide Hines with the drug.

Moral of these stories

The moral of these stories is that policyholders don’t have to take no for an answer. Insurance companies often deny claims in the hopes that policyholders will simply accept their decision and go away. However, if you go the extra step, you just might be able to get the coverage you need. While the three individuals above did not need to seek the advice of an attorney, that is also an option that policyholders have in their arsenal to reverse claims decisions that seem to be made in a vacuum or in bad faith. Consultations are free, without obligation and are strictly confidential.

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