So you received a letter from your health plan and it states that they are not going to pay for your recent surgery because it is not a covered benefit under your policy.  A few things may be running through your head at this point:

Medical Claim Denied“Why didn’t they tell me this before?”

“How am I going to come up with the money to pay for this huge hospital bill?”

“Is there something I can do to fight this denial?”

Many people who have received a claim denial from their health plan have had these thoughts, especially the last one about fighting the denial.  Unfortunately, most people dismiss the idea of appealing the denial thinking that they I could never get the insurance carrier to change their decision. So why bother? Right?  Wrong!

You have to make an attempt to appeal the claim denial.  What’s the worse that can happen? Believe it or not, health plans do make mistakes and they do correct those mistakes when someone shows them information they may not have considered.

Here are some quick steps for sending an appeal on your own:

  • Call your health plan and ask the representative for a clear explanation of why they are not paying your claim;
  • Research the facts to see if you need to review your policy or possibly follow up with your physician’s office or hospital for assistance.  REMEMBER: your physician and hospital want your health plan to pay the claim just as much as you do;
  • In your letter to your health plan, state exactly why you disagree with their decision and what you are looking for the health plan to do for you;
  • Submit the appeal letter with any supporting information, i.e. a copy of a page from your policy or your medical record, to the health plan and be sure you follow up by phone until you get resolution;
  • If your health plan continues to deny the claim, try appealing again and keep pushing it up the chain of command at the health plan; and
  • Once you have exhausted your appeal rights at your health plan, you have the right have your appeal reviewed by an outside company.  Check with your state Department of Insurance for details if your health plan does not supply that information to you in their denial letter.

Battling a health insurer when it refuses to cover certain treatments can be aggravating and time-consuming.  But it can be worth the effort as health plans do overturn claim denials.  Remember, you don’t know if you don’t try.