A health insurance dispute may arise when an insurance company refuses coverage, declines to cover certain medical procedures, or charges unaccountable fees.
Before resolving the dispute formally, you may seek informal solutions by contacting the insurance company. Seeking informal resolution will enable you to collect important information for a potential legal action.
If your coverage has been denied or an improper charge has been applied to your account, you may ask your insurance company to review the matter. Internal review is an internal appeals process that may efficiently resolve an error. Several steps should be taken before filing an internal review.
Before filing for an internal review, you should complete the following steps:
- Review the insurance agreement, including the Summary of Plan Description and the Evidence of Coverage.
- Contact customer service and ask for the reversal of an improper charge or coverage denial.
- Develop a record of all the documents and conversation that relate to the dispute.
- Request a formal letter of denial from the insurance company.
Make sure to file for an internal appeal within the appropriate deadline. If the deadline is missed, your internal and later external appeal rights may be jeopardized.
To support your arguments in the internal review process, you may consider preparing and submitting the following materials for the insurance evaluation:
- Relevant sections and provisions from your Evidence of Coverage
- Your doctors’ explanations of why the condition should be covered
- Opinions of other doctors regarding your condition and treatments
- Billing statements and other documents evidencing payment
- Additional information about your medical condition
- Information on treatment of your medical conditions
- Explanation of benefits forms
When it comes to the actual internal review process, there are several things to keep in mind:
- If the first internal review is not successful, you may apply for a second.
- The second internal appeal may involve a panel, committee, or hearing.
- If the second review involves a hearing, you may be required to attend.
- A lawyer can help you prepare for and attend an internal hearing.
- An arbitration may also take place in addition to the internal review process.
- During arbitration, you will be required to make arguments and present evidence.
After you file an internal review, the insurance company must respond within a certain time. Your Evidence of Coverage may tell you the specific timeframe. If you’re in danger of suffering adverse health effects, you may ask for an expedited response. In such case, the insurance company may have to respond within 72 hours.
To summarize, the following processes may be involved in disputing your insurance decision:
- First internal review
- Second internal review
- External (independent) review
- A legal case in the court
Disputes with health insurance companies are often complex and your rights may depend on provisions in your health insurance contract as well as the laws of your resident state. To be successful in your claim, you should consult a qualified insurance lawyer.