Understand Health Insurance Coverage and Resolve Denied Health Claims

By Marilyn Katz

A health insurance policy is a contract between you and your medical plan company. It outlines the medical procedures that are covered, what portion of a bill the insurer will pay, and under what circumstances services are covered. For instance, a PPO plan may cover an in-network doctor's visit with a $40 copay, but only pay 50% of the doctor's bill if you choose to find a physician out of the network. They may cover 100% of medication which is prescribed in a network hospital, but only cover 50% of medication, after a $500 deductible, which are purchased in a drug store. These are just examples, and are not meant to outline the coverage of any particular medical plan. The point here, is that health coverage can be complex, and it is important to take the time to understand you own personal policy.

Another point to consider is that just because a doctor determines that you need a particular medical procedure does not mean that your plan covers it. Understand that there is a difference between your own contract with an insurer and what a doctor thinks you need. You also cannot expect your own physician to be familiar with every single medical plan his patients have. Many doctors will try to work with the coverage you have, but they can only do that if you help them.

So we all know that insurance companies do deny claims. If you believe that you should be covered, it is your responsibility to dispute that claim. Here are the steps that we think you should take.

• Call customer service first. We have found many examples of medical claims being denied because of a medical coding error. See if you can get the issue resolved at this level first. If no error has been made, make sure you understand why your own medical plan denied the claim. If you believe your insurer stuck to the terms of the policy, then you probably need to accept the bill. However, if you believe the insurer did not follow the terms of the contract then you have just begun the dispute process.
• Find out your health plan's arbitration process. This should be outlined in the brochure that came with your own policy, If you do not have the brochure or booklet, get the information from customer service.
• Contact your own state's insurance department. Sometimes they can step in and resolve the claim. However, they will only be effective is your insurer broke any of your state insurance department's regulations.
• Get a lawyer. Because lawyers are expensive, and because they cannot assure you will prevail, this should be a last step unless your situation is very urgent. Some lawyers will work on a contingency basis, where they only collect if you win the case. Your initial consultation should be free, and that is the time when the lawyer can tell you if you have a good case.

Understand your medical plan before you need to use it. Try to help you doctor understand what is covered. If you do have a problem, try to resolve it with the health insurance company first because this process does solve many problems. If that doesn't work the state insurance department and the laws of your state are put in place to protect you.

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