What You Should do if Your Insurance Claim is Denied

Filing an insurance claim is often directly preceded by a traumatic event in your life. So the last thing you need is a fight with your insurance company to force it to pay. But you can take steps at every point in the process — and even before a traumatic event occurs — to help make sure you get satisfaction.

People who do some planning are going to get through the claims process most easily. For example, in 2005, Hurricane Katrina’s storm surge engulfed much of the southeastern US and left homes underwater. It was about a year and a half before some people could get insurance payouts and move back into their homes. Technology has helped smooth the claims process since then. Smart-phone cameras, insurers’ apps, Web tools and other resources can help you prepare before a claim, submit information and gather evidence to support your case if your claim is denied. Even if you take preventive measures plus steps to file a hassle-free claim, you could find yourself losing a tug of war with your health, homeowners or auto insurer over how much it will pay. These tactics will help you fight back.


Your Right to Appeal

Th most common type of insurance denial comes from health insurance claims related to injuries, treatments, and medical condition. Health insurance claims are the most common and also the most involved and complex types of claims to file which is why there is such a high percentage of denials. Even if you have be denied coverage for a medication, treatment, or other medical care that your doctor says you need, you can appeal the decision.

The Affordable Care Act (ACA) ensures your right to appeal health insurance plan decisions. Under this law, if you disagree with your insurance plan’s refusal to approve or pay for care, you have the right to appeal through the health plan’s internal process, which may involve several levels of appeals. Your health plan cannot drop your coverage or raise your rates because you ask them to reconsider a denial. This may involve a request for pre-authorization of a service or claim for services already rendered.

Your plan must notify you of:

  1. The reason your claim or coverage was denied n Your right to file an internal appeal with instructions on how to submit;
  2. The deadline in which you need to submit your appeal; and
  3. The availability of a Consumer Assistance program (in some states)


There are two ways to appeal a health plan decision, according to the US Healthcare Marketplace website:

  1. Internal appeal: If your claim is denied or your health insurance coverage canceled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
  2. External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim.


Understanding the Cost of Your Lawsuit Claim

At times,  though it is rare, repeat denials of insurance claims can play a part in medical malpractice and could be used as part of the process of filing a medical malpractice or medical based lawsuit. Before considering this option though, it is important to know the cost of what you are getting into. In legal practices, “costs” is not the same as the fees that are paid to your accident lawyer for their services. Instead, costs refer to the expenses paid by the lawyer’s office in investigating your claim and representing you and presenting your case to the judge. There are many aspects of costs that can affect the final dollar amount and this is added to any fee that you may also be required to pay to the attorney.  Depending on the agreement you reach with your lawyer, you will have to repay the lawyer for these costs, usually out of your final settlement amount. Some costs are unavoidable. For example, if the lawyer must file a lawsuit to protect your rights, the fee for filing that lawsuit is a necessary cost.  There are several matters pertaining to costs that you and your lawyer need to discuss and spell out clearly in your written agreement.

To learn more and see what we can do for you in determining the best course of action for your insurance denial situation give us a call!