Disputes often arises between the insured client and health insurance company regarding payments or coverage of service. As part of the dispute with an insurance company, you may be required to go through a series of reviews. These reviews are basically appeals, at first to your insurance company and then to an independent organization. If all the appeals do not resolve the issue, you may need to sue your insurance company.

Outline of the Appeal Process

The process of appealing an insurance decision typically includes the following:

  1. First internal review with the insurance company
  2. Second internal review with the insurance company
  3. An independent or “external” review
  4. A lawsuit

What Is the First Internal Review?

In the first internal review, the insured person asks the insurance policy to reconsider its decision that denies, limits, or withdraws coverage, or affects some other aspect of coverage or a payment of a charge. One must study the insurance policy carefully to ensure that all necessary steps are properly followed. To support your position during this first appeal, you may prepare:

  • Your doctor’s opinion supporting your position (i.e., that a medical procedure is necessary)
  • Second opinions of other doctors
  • Additional explanations about your conditions

What Is the Second Internal Review?

The second review or appeal is also filed internally with the insurance company. There is no need to file a lawsuit yet. The second internal review may take many forms – a hearing, a committee, special panel, arbitration – which may require your attendance. In order to provide a strong defense for your position, you may wish to consult a qualified attorney at this time.

Appealing the Second Review: What Is an External Review?

If the second internal review results in an adverse decision, you may be required to appeal again depending on the state law and the type of insurance at issue. The external or “independent” review is undertaken by a third party. If your state doesn’t maintain such an entity, the Department of Health and Human Services (HHS) may oversee the independent review. Keep in mind:

  • You doctor may file an external review on your behalf.
  • This external appeal is either free or comes at a small fee.
  • The appeal for external review must be filed within 60 days of the prior denial letter, and the review itself typically takes no more than 60 days.
  • Documents such as denial letters may provide more information about the external appeal in your state.

When the Appeals Fail, Should You Bring a Lawsuit?

After exhausting the appeal process, you can still seek to enforce your claim through a lawsuit. You may need a qualified lawyer to file a “bad faith insurance” case against your insurance company. Even if you file a case, it doesn’t mean that the case will necessarily be litigated. Instead, you may achieve a favorable settlement.

Seeking Help from an Attorney

Disputes with insurance companies can be highly complex. To achieve success with your claim against your insurance company, you should consult with an experience insurance lawyer. An attorney can guide you through the appeal process and, if necessary, can bring a civil lawsuit against your insurance company.