ElderLaw News

ElderLaw News is a weekly e-newsletter that brings you reports of legal developments and other trends of vital interest to seniors and their advocates. This newsletter is brought to you by The Estate Planning & Elder Law Firm, P.C., William S. Fralin, Esq., President.

Appealing Health Insurance Coverage Denials

A recent Wall Street Journal article addressed the issue of consumers battling health insurers when the insurers refuse to cover certain treatments.

Some coverage questions can be resolved with a telephone call; other issues may be more complex.

If the issue is a complex medical one, such as whether a treatment is appropriate, then the consumer may need to ask their physician for assistance in resolving the problem. If all else fails, then most states will consider appeals that have been denied by private insurers. The New York State Insurance Department keeps track of appeals filed with health insurers; 33,355 appeals were filed in 2007, up 18% since 2004.

Appealing an insurer's decision can be difficult, but there are some things consumers can do to increase their odds of success:

-- First, you need to gather the facts. You will need the denial letter, because you will have to determine why the insurer denied the claim, and you must learn the insurer's process for appeals. Whenever you talk with someone from the insurance company, get the person's name and take notes. You should get a copy (often available online) of the plan's full benefits ("evidence of coverage"), and the guidelines for medically necessary coverage. Sometimes the insurer only needs additional information from you or your physician in order to process the claim; this may happen in the case of a denial for lab testing for which the insurer did not have a copy of the physician’s authorization.

-- After you gather the facts, you need to determine your strategy. You may have to prove that your treatment is covered under your plan. Additionally, you may have to prove that the treatment is medically necessary and scientifically proven. There are organizations that can help consumers gather the necessary information for appeals. One such nonprofit group, the Patient Advocate Foundation, is based in Hampton Roads, but it serves clients nationwide.

-- If your insurer rejects your appeal, then you may be able to sue in federal court, but this is a costly and difficult alternative. This may be necessary if your employer has a self-funded health plan. If your coverage is with an insurance company, you may be able to work through the state's appeal process. You will need to check with your state's insurance department to see if this agency will handle your type of case. For Medicare beneficiaries, there is a separate federal appeals-review process.

The healthcare system is becoming more complex, and consumers are asked to make many of their own choices. Consumers should continue to educate themselves about their insurance coverage, but they should also be aware that there are patient-centered organizations that can help them navigate the maze.

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