Health Insurance Disputes

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When Do Health Insurance Disputes Arise?

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.

How to Address a Dispute with a Health Insurance Company

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.

Preliminary Considerations for an Internal Review

Before filing for an internal review, you should complete the following steps:

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.

How to Support Your Position in the Internal Review Process

To support your arguments in the internal review process, you may consider preparing and submitting the following materials for the insurance evaluation:

The Actual Internal Review Process

When it comes to the actual internal review process, there are several things to keep in mind:

Hearing Back from the Health Plan: When to Expect a Decision?

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:

Seeking Legal Help

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 health insurance lawyer.

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Last Modified: 08-30-2016 03:12 PM PDT

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