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Health insurance claim denial recourse or when you shouldn't take "no" for an answer

By Megg Mueller on December 22nd, 2010

Health Insurance

Anyone who's had health insurance for any length of time is pretty familiar with all of the rules, steps, and hoops you have to go through to get coverage. Suffice to say, insurance companies don't necessarily make the process an easy one. But once you've found a provider on your insurance plan, made an appointment and had your visit, most of us would feel safe in assuming our health insurance would pay for the health service. Unfortunately, that's not always the case.

The story of a health insurance claim denial

A story from Reuters tells how a writer saw a nutritionist to help her deal with her dangerously high cholesterol; the nutritionist was an approved provider of her Empire BlueCross BlueShield plan. When the bill came due, the insurance company decided the cholesterol issue wasn't a complicating medical condition, and as a result, the writer was on her own for payment.

Don't just take 'no' for an answer

This isn't an unusual incident, sadly, but many people don't think to double check if a visit is covered. With all the criteria we have to follow to see a doctor these days ("do they take my insurance; are they in-network; do they see new patients; can I get in to see them before next year" are just a few that roll through my head) it's no surprise many people incorrectly assume they'll be covered if they've followed the rules. But if you've made such a mistake, repeat after me: No doesn't always mean no.

Health care reform will require every new group plan after Sept. 23 2010 to have an external review process in place for patient appeals. While grandfathered plans won't have to comply with this new provision, it's comforting to note that 44 states already have laws on the books that require insurers to have a process for external reviews.

If your bill is refused, appeal. The Reuters writer ended up having her bill paid, but it took effort on her part to appeal the claim. If you need help, here's an example of an appeal letter you'd send when refuting a claim your procedure or care wasn't medically necessary. Good luck!

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