When Insurance Won't Pay


CBS
March 16, 2001

 Now more than ever, people are relying on health insurance to protect them from the high cost of medical care. Health claim processors, however, say there's been a sharp rise in the number of claims being rejected or simply ignored by insurance companies. As a result, families are sometimes saddled with medical costs they thought would be covered.

 Legal expert and attorney Robert Tarver joined the CBS Early Show to give advice on what to do if an insurance company refuses to pay. Tarver spoke with a number of health claim processors, and found claim rejections are a result of many factors, including processing errors and the failure to process in a timely manner. Many processors allegedly operate under a system that rewards speed in the processing of claims. This means the more complex claims often fall by the wayside and are either processed incorrectly or not processed at all.

 Tarver says the best way to deal with unpaid insurance claims is to first try to resolve them with the company. The first step: Speak with a claims supervisor, not just a representative. There is a tremendous amount of power vested in supervisors. Quite often, forming a good relationship with them can mean the difference between getting your claims paid and owing money to a doctor.

 If that does not work, then the next step is to contact your state insurance commissioner, who is responsible for overseeing insurance companies. Send in a letter about your complaint. Tarver says the insurance companies will often respond much more quickly to a regulatory agency than they will to an ordinary citizen.

 If all else fails, take your insurance company to court. You should understand that the law favors you in a suit against the insurance company because most insurance contracts are issued on a take-it-or-leave-it basis, meaning it's not negotiable. Many courts will reportedly favor the weaker party and anything ambiguous will be resolved in favor of the insured.

 In order to be successful in any suit, you must first look at your insurance policy to make sure you are, in fact, covered under the terms of the policy. Remember: A policy is a contract and the insurance company is only responsible to pay what they contracted to pay.

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