Getting your medical expenses covered by your health plan can be frustrating, but a little knowledge can go a long way.
The Basics
You can start by checking the following on your health plan:
- Do you need a referral from your primary care physician in order to see a specialist?
- Does the plan require prior authorization for a planned surgery or hospital stay?
- Do you have to select a physician from a network for the charges to be fully cored?
- What does your plan cover?
- What does it limit or exclude?
Don't Be Stopped By Denials
If your health plan refuses to pay for treatment, you can and should consider appealing if:
- The treatment isn't a covered benefit, but you think the health plan should make an exception for you, or
- You have support from your physician that the treatment is "medically necessary," or
- The treatment is deemed by the insurance company to be experimental or investigational.
Call the company that issued the denial, armed with a file of your medical and insurance information, including your benefit plan and summary.
A customer service representative can't overturn your denial, so ask to speak with a supervisor.
Making a Formal Appeal
Every managed care organization is required by law to have an appeal process.
Although an appeal process isn't perfect, it's much less of a financial and emotional burden than litigation. And your contract with the health plan may prohibit you from filing a lawsuit before filing an appeal.
When formally appealing:
- First, read the appeal process guidelines in your policy. Familiarize yourself with timeline requirements.
- Put your complaint in writing, including:
- Your health problems and treatment history
- How you have exhausted all other reasonable alternatives
- Physician recommendations
- Why you are an ideal candidate
- What will happen if treatment is not approved
- Support letters from your physicians
- Quotes from the benefit plan if it contains helpful language
- Medical records that support your position.
- Enlist your doctor's help. Your doctor willing to advocate for you.
- Track relevant dates to ensure that your complaint is moving forward expeditiously.
- Be prepared to spend a lot of time on the phone.
- Keep a record of all communications, including the date and time of your conversation, the full name and title of the person with whom you spoke, and a summary of what was discussed.
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Insurance Law
Most insurance policies require that insurance premiums be paid either at the beginning of the policy period or at designated times during the policy period. If the insured misses a payment, the insurance policy usually lapses unless the insurer agrees to accept a late payment and continue the policy. However, in certain circumstances, the insurer's conduct can estop or prevent the insurer from claiming that the policy has lapsed for nonpayment of premium. The insurer, by its conduct, can also waive the right to claim that the policy is no longer in force due to the failure to pay the premiums. Estoppel or Waiver
An insurer can lose its rights by its conduct. For example, a life insurer which allowed the insured to believe that he was covered up to time of his death can be estopped to claim, or be prevented from claiming, that the policy lapsed for nonpayment of premium.The waiver of the right to assert the forfeiture of the policy for nonpayment of premiums happens when the insurer expressly or impliedly leads the insured to believe that the insurer has relinquished such rights. For example, if the insurer did not tell the insured that the insured's policy was forfeited for nonpayment until after a fatal accident occurred and the insurer's application for continuance of coverage indicated that coverage would continue, the insurer has waived its right to assert that the insured's policy was forfeited.
The right to enforce a forfeiture of a policy for nonpayment of premiums is not waived by the mere silence or inaction of the insurer. For instance, if an insurer failed to mention to a former insured that her policy had lapsed when the former insured asked for coverage on a different car, the insurer is not estopped to deny the existence of the policy.
An insurer that accepted a payment and deposited the check without following its normal review process and that clearly knew that the policy had lapsed when the payment was received has waived the right to claim forfeiture of the policy due to nonpayment.
An insurer, by prior acceptance of late payments and earlier reinstatements, does not waive its right to declare a forfeiture of the policy for a new missed payment.
If an insurer has been authorized to withdraw premiums from the insured's bank account and there are insufficient funds in the account, the insurer's subsequent notice of insufficient funds does not waive the insurer's right to forfeiture of the policy.
An insurer's acceptance of the premium constitutes a waiver of the right to forfeit the policy on the ground that a prior month's premium was not paid where the insurer deposited the check knowing of the dishonor of the check tendered for the previous month's payment.
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