Fight a Denied Health Claim

Kiplingers.com
December 28, 2001

by Kimberly Lankford

I've been fighting with my health insurance company to get my claim paid. Where can I go for help?

First, call the insurer's customer service department and ask why the claim is being denied. Take notes of whom you talked with, when and what he or she said. This may all come in handy if you need to appeal the decision.

Next, look at your insurance policy, especially the exclusions section, to see if the explanation makes sense.

If it doesn't, look through your policy for information about the company's appeals process. Companies usually let you go through several levels of appeals if you believe your claim has been denied inappropriately.

You usually must start your appeals process by stating your case in a letter. Eventually you'll present your case to the insurer's appeals board.

If you've exhausted the insurer's appeals process and the denial still hasn't been reversed, you may be able to take your case to an outside review board, if one is available in your state. Each state has its own rules for contesting health-insurance denials and different places to go for help.

Some states have managed-care ombudsmen, who can walk you through the insurer's and state's appeals process, and even help you present your case. Other state agencies merely gather complaints and investigate a company if there's a pattern of problems. Some states have separate offices for HMO and non-HMO issues.

However, if your health plan is self-insured by your employer, your state won't be able to do much at all -- those plans fall under the jurisdiction of the U.S. Department of Labor. Regardless of where you'll ultimately need to go, most states have a general number you can call for help. Visit the  Kaiser Family Foundation's State Health Facts Online (www.statehealthfacts.kff.org) for a list of resources in your state.

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