One way you can get help fighting or suing the health insurance companies is through your state insurance department. One of their jobs is to protect health insurance consumers and help them with issues that they may have with their insurance companies.
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Before you contact your state insurance department, there are steps that you can take to fight your health insurance company on your own. Often you can settle things on your own before you take more extreme measures.
Why do health insurance companies deny claims?
The biggest reason most people want to fight health insurance companies is because the company has denied a claim that was submitted. If this has happened to you there are a number of reasons why the company may have denied the claim.
One reason may be because you submitted a health insurance claim for a service or procedure that is not covered by your policy. Things that are excluded from your policy may include conditions that are pre-existing, experimental drugs or treatments, or things that are not medically necessary.
Another reason that your health insurance company may reject a claim is that you received care or services from a physician who is not covered under your plan. If you have HMO health insurance or another plan that requires you to use only the health care providers in their network, your claim will not be covered if you someone out of the network.
One of the biggest reasons a claim is denied is because of clerical errors. This includes an incorrect member number, policy number, birth date, or diagnosis code. This may be something that you wrote down wrong or something that your physician or billing provider entered incorrectly.
What should you do if a claim is denied?
If a claim that you submitted was denied by your insurance company, you will receive a letter or an EOB, which stands for explanation of benefits. Take note of the reason why the claim was rejected. If you don’t understand all of the codes or terminology you should call the company and have a customer service representative explain why it was denied in more detail.
If it was denied because of a service or provider that was not covered by your policy, there is not a lot you can do to fight the denial. It would more than likely be a waste of your time. To prevent anything like that from happening again you should always closely look over your policy. If you have questions about any of the terms used, you can get help from the Insurance Information Institute.
If your reason was a clerical error, this is an easier fix. If it was an incorrect diagnosis or service code, contact your health care provider and have them resubmit the claim with the correct information. This is also a good route to take if any personal information is incorrect.
If you feel that the claim was denied for no good reason you should send in an appeal. Gather as much information about the claim you can. Write a letter to your insurance company outlining why you feel the denial was a mistake.
Explain in as much detail as possible your arguments against the denial and explain what you want the outcome to be. Send copies of all supporting documents with your letter to the insurance company.
Once the health insurance company has investigated your letter they will respond back. They will either overturn the denial or stay with their decision. If they did not overturn it you can contact your state’s insurance department.
What will the state insurance company do for the denied claim?
The state insurance commissioner is there for a number of reasons. One reason is to help you fight a claim that was wrongly denied, another is to keep track of consumer complaints about health insurance companies. Contact the state insurance department with the same information you sent to your insurance company.
The state department will perform their own investigation into the claim. Sometimes a third party helps to reverse a denied claim. To contact your own state insurance department, you can click on your state on the National Association of Insurance Commissioner’s website.
If the state department cannot get the denial reversed, you can hire an attorney. Keep in mind that it will be expensive, however, and may not be worth your time and money.
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