Resolving a Health Insurance Claim

If your health insurance company is disputing a claim, getting them to honor it is going to be a tough battle. It can be a very difficult, very long process—but it’s possible, and it’s worth it, giving the ever-increasing nature of the costs of healthcare. Increase your chances of winning the battle by following these steps.

1) Gather your Paperwork

Locate all the paperwork that’s relevant to the claim.

• Your policy
• The relevant medical bills
• Any correspondence from your insurance company relating to the claim

2) Check the Fine Print & Prepare your Documents

Check your insurance company’s denial of claim information and make sure you understand why the claim hasn’t been paid. It may just be a simple matter of the medical staff at the office you visited failing to supply some necessary information to your insurance company. If this is the case, the claim will be much more easily resolved.

Check your policy’s fine print for exclusions that might indicate why the insurance policy is disputing your claim. You may find that the procedure that’s under dispute is specifically mentioned as an exclusion and you simply weren’t aware of it. If this is the case, you’re probably out of luck, as the insurance company will not honor your claim. On the other hand, if the procedure is not specifically mentioned, or if the exclusions relating to the procedure are open to interpretation, you may still benefit from talking to your insurance company.

Before calling your insurance company, go through your documents and highlight or circle all the information you might need when you talk to a representative such as dates and invoice numbers in your medical bills and correspondence relating to the claim, and relevant exclusions in your policy.

3) Call your Insurance Company

Talk to a claims adjuster or customer service rep. Explain that you have carefully checked your policy and supporting documentation, and that you believe the claim was denied in error. Ask them to provide a date by which the claim will be resolved, and don’t hang up until you get it. Make sure you obtain the name of the person you’re speaking with, and call them back on the date given if your claim has not been resolved.

Remember to document all of your phone conversations with your insurance company, including the time and date and the outcome of the conversation, as well as the name and position of the person you spoke with.

4) Consider Filing an Appeal

If your claim isn’t successfully resolved, you may consider filing an appeal. Each state has a slightly different process for this—contact your state’s department of insurance to find out more about how to file a claim.

Note that in most states you’ll have a limited amount of time in which to file your appeal. In California, for example, you must appeal within six months of the denial of your claim. In New Mexico the time limit is 20 working days, and in Texas there is no time limit. Each state is different, so it’s important to get an appeal started quickly if you’re not sure how much time you have.