If you object to the way your insurer paid your claim, start
by calling your plan’s benefits administrator, if you have one,
or check with your human resources department. If your
objections are still unresolved, your next step is to file an
appeal a means of objecting to the way the insurer paid
your claim and requesting the insurer to reconsider the claim.
Check your health insurance policy for a section on the
appeals process. Your plan may spell out each step that you
must follow to appeal your claim. Be aware of deadlines that
you must meet to resubmit a claim, or you may lose your
right to appeal.
Follow up on the response you receive from the insurer. Read
it carefully and make sure that the insurer bases its decision on
the correct information. If you discover that some of the information
you submitted on your original claim is incorrect or
inaccurate, notify the insurer in writing of the correction.
Mail correspondence by certified mail with a return receipt
to confirm that the insurer received your letter.
If the insurer continues to deny benefits, submit copies of
the claim, correspondence, notes, and the relevant pages of
your policy to your state’s insurance department. Remember
to include your policy or claim number. Write a cover letter
explaining in detail why you think the insurer did not properly
pay benefits for your medical expenses.
The department of insurance notifies the insurance company
of your complaint. The insurer must then respond to the state
insurance department within a specified period, usually 10
to 30 days. After the insurance department receives the
insurer’s response, it investigates and comes up with a solution,
if possible. Expect this process to take at least 30 days
(longer if the case is complicated).
As you work through the appeals process, keep in mind that
each state has its own laws usually referred to as the Unfair
Claims Settlement Practices Act to protect you from
unfair and deceptive practices in the insurance industry.
For more information on your particular state’s laws, contact
your state’s insurance department. To find your state health
insurance contact, check with the National Association of Insurance Commissioners (see the Resource Center for
contact information).
Although the insurance protection laws differ from state to
state, most of them have the following provisions in common.
The laws state that insurance companies:
- Must not intentionally misrepresent facts or provisions
relating to coverage under your policy, such as stating
that a condition is covered when it isn’t.
- Must acknowledge your claim and act promptly in
response to your communications about your claim.
- Must put into action standards for timely investigation
and processing of claims.
- Must not attempt to influence payment of a claim you
make under one benefit provision (such as a hospital
benefit) by delaying payment under another (such as a
prescription drug benefit) when the amount the company
owes you is clear.
- Must not delay an investigation or payment of claims by
asking you for reports or forms that are unnecessary or
contain information that you’ve already submitted.
- Must not force you to file a lawsuit to recover money due
under an insurance policy by offering you considerably
less than the money ultimately recovered in a lawsuit.
- Must not, as a policy, appeal arbitration awards in your
favor to force you to accept a settlement amount or compromise
for less than the amount awarded in arbitration.
Both sides choose one independent third party, such as
a judge or lawyer, to determine the outcome (arbitrate).
The decision the arbitrator makes is usually final.
- Must not refuse to pay your claim or delay payment
without conducting a reasonable investigation and giving
you a valid reason.
If you think that your insurance company is violating the
Unfair Claims Practices Act, talk to a claims supervisor at the
company and explain your concern. If that doesn’t help
resolve your problem, file a complaint with your state’s insurance
department.
The state insurance department can help only if the insurance
company has broken the law. It can’t force the insurer
to provide a benefit that isn’t in the health insurance policy.
Many state insurance departments try to resolve the complaint
by phone before the consumer resorts to filing a formal
complaint.
If you hire a lawyer to resolve your complaint, the state insurance
department won’t speak with you directly. As your legal
representative, your lawyer speaks for you.
If their finding is against the insurance company, state insurance
departments have the authority to impose penalties on
an insurance company, ranging from assessing a fine to revoking
the company’s state license.
Recognizing Your Emergency Room Rights
The Emergency Medical Treatment and Active Labor Act of
1998 (EMTALA) states that hospitals must give appropriate
care to people regardless of their ability to pay, including people
whose health insurance coverage restricts emergency room
benefits. Hospital staff can’t postpone examining a patient
while checking on insurance coverage or while trying to get
permission from a doctor in the patient’s health plan network
to examine or treat the patient.
Individual state laws may offer rights in addition to the rights
in EMTALA. Some states have a regulation that requires insurance
companies to pay for emergency room care if a prudent layperson (a person with an average knowledge of health and
medicine) acting reasonably would consider the situation a
medical emergency.
Emergency room staff must do a medical exam before sending
you to a clinic or doctor’s office. The exam determines
whether you need immediate care and avoids putting your
health at risk. If emergency room doctors determine that you
have an emergency medical condition, they must stabilize or
appropriately transfer you to another medical facility.
EMTALA defines an emergency medical condition as a medical
condition with symptoms so severe that you could reasonably
expect the lack of immediate medical attention to result in:
- Seriously jeopardizing a patient’s or unborn child’s health
(in the case of a pregnant woman)
- Seriously harming any bodily functions or parts
When a pregnant woman is having contractions, EMTALA
considers it an emergency when
- There isn’t enough time to safely transfer the pregnant
woman to another hospital before giving birth
- Transferring the pregnant woman may threaten her health
or safety or the health or safety of the unborn child
If your condition doesn’t meet the definition of “emergency
medical condition,” the hospital emergency room doesn’t
have to treat you.
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