What can we do about a claim that was denied?

UPDATED: Dec 10, 2013

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What can we do about a claim that was denied?

We took out some medical insurance out on my wife. One of the questions asked on the application was if she had had COPD. We were not aware that she had this condition and answered the question with a “No”. My wife had an unrelated CODP health claim turned into the insurance company. During the review process for pre-existing conditions, her pulmonary doctor stated that she had asthma with elements of COPD. Again we were not aware of this diagnosis at the time of the application. Due to this the insurance company has rescinded the policy for this year and will not be paying on her non CODP related health claim. Their response was to talk to the doctor to see if he could change his diagnosis and then send in an appeal to the insurance company.

Asked on December 10, 2013 under Insurance Law, Florida


FreeAdvice Contributing Attorney / FreeAdvice Contributing Attorney

Answered 8 years ago | Contributor


Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming. But if you choose to appeal a coverage denial, there are several strategies that can bolster your case.


Some health-coverage problems — such as when your doctor enters a wrong code on a claim form — can be resolved with a phone call. But other issues can be more difficult, because they center on complex medical questions like whether a certain cancer treatment is appropriate for you.


First, figure out what led to the denial of coverage and learn your insurer’s procedure for appeals. When you call your health plan to get the information, take notes and get names. If the problem can’t be readily resolved, you should ask the insurer for some key documents to reconstruct what led to the rejection.


You will need the denial letter. You should also get a copy of your plan’s full benefits language, sometimes called the “Evidence of Coverage,” as well as the detailed guidelines that explain what the company considers medically necessary. Some companies, such as Cigna Corp. and Aetna Inc., post their medical policies online.


After you gather the facts, set a strategy. You may want to start by seeking help from one of the array of nonprofit and for-profit entities that offer advice. Many states have health insurance consumer advocates. The advocacy group Families USA offers a list of state resources.


Another key resource is the nonprofit Patient Advocate Foundation, which handles health-insurance appeals for free. Other organizations and companies can be found at the following Web sites:


Your appeal may hinge on proving that your treatment qualifies for coverage under your plan’s benefits and rules. In that case, you will want to zero in on the plan’s language, and figure out why the procedure you are seeking fits into a category of care that the insurer has promised to pay for.


Many appeals hinge on a different issue: whether a treatment is scientifically proven and medically necessary. Your doctor should be able to write a detailed letter on your behalf. You also may be able to bolster your case by researching the scientific evidence online on sites like pubmed.gov, sponsored by the National Library of Medicine. You are seeking studies that may demonstrate that the treatment you want has worked in cases similar to yours. The strongest evidence comes from large, randomized, controlled trials, but anything published in a reputable medical journal might help. You should show your findings to your doctor, so he or she can explain anything you don’t understand, as well as integrate anything important into his or her letter to the insurer.


You may also want to seek help from researchers who worked on the cutting-edge studies you find – sometimes, these doctors are willing to help a patient with an urgent case. They might even review your medical records and submit a backup letter on your behalf, which can add weight to your own doctor’s views.


Even if your insurer rejects your appeal, you still have other options. If your employer has a self-funded health plan, which might be administered by a private insurer but is backed by the employer, your next step is often to sue in federal court, a tough and expensive proposition.


But if your coverage is with an insurance company, either through your employer or an individual policy, you can opt for your state’s appeals process. Often, these are handled through the state’s insurance regulator, but if not, this agency should at least be able to tell you where to go. Make sure you check with the agency, because the 44 states that offer independent reviews won’t handle all kinds of issues, and each has its own rules. For Medicare beneficiaries, there is a separate, federal appeals-review process that you can learn about at Medicare.gov.


IMPORTANT NOTICE: The Answer(s) provided above are for general information only. The attorney providing the answer was not serving as the attorney for the person submitting the question or in any attorney-client relationship with such person. Laws may vary from state to state, and sometimes change. Tiny variations in the facts, or a fact not set forth in a question, often can change a legal outcome or an attorney's conclusion. Although AttorneyPages.com has verified the attorney was admitted to practice law in at least one jurisdiction, he or she may not be authorized to practice law in the jurisdiction referred to in the question, nor is he or she necessarily experienced in the area of the law involved. Unlike the information in the Answer(s) above, upon which you should NOT rely, for personal advice you can rely upon we suggest you retain an attorney to represent you.

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