FAQ: What if My Health Insurance Claim is Denied?

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If you are in the position of having your health insurance claims denied, do not give up without a fight. Although it may feel as if you have reached a complete halt with your medical insurance provider, do not take their denial as the final word. By following a few simple steps, you may actually stand a good chance of getting properly reimbursed for your medical care.

Fighting Your Denial

  • As a member of a health care plan, it is important that you fully educate yourself to get the lay of the land. You need to verse yourself on exactly what your insurance company covers as well as investigate the local laws, as there are state and federal laws in place for how insurance companies need to legally handle complaints and appeals when a health insurance claim has been denied.
  • Once you are armed with knowledge, organize your paperwork including your research, the insurance company’s Explanation Of Benefits form they sent with your denied claim and a copy of the policy. Call the insurance company, speak professionally and provide all the evidence to make your case. This phone call may do the trick, but it is still important that you take detailed notes regarding the conversation, what was said, whom you spoke to and the date and time of the conversation.
  • If verbal communication has failed and your health insurance claim is still being denied, put your complaint in writing. What you need to construct is a “written appeal” of the denied health insurance claim. The best defense is to clearly address the exact cause of denial that was in the Explanation of Benefits letter. For example, if your health insurance claim was denied as it was deemed “unnecessary,” then include a copy of your medical records to prove otherwise. Be prompt when filing your denial claim as there is often a cut-off date for when written appeals can be made.

At this time over 43 states have a Patients Bill of Rights when it comes to managing their health insurance. If your claim is still denied, you can request an independent review. According to Parade Magazine, it is important to take the appeal process to the final level: “Although success rates differ from state to state, consumers tend to prevail in these challenges about 50% of the time.”

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