Your HMO will not provide you with a referral for your autistic son to have speech therapy. Your PPO refuses pay an emergency room bill from two years ago. Or your short term policy dropped you for no good reason. Where do you turn?
While it may feel like your hands are tied, in fact you have options in order get the care and coverage that you deserve. While it is easy to feel like the little guy fighting city hall, you have rights when it comes to your insurance coverage. The key is to know to right channels and the right methods to get the outcome you deserve.
When you first realize that an insurance company has made a determination that you would like to dispute create a file to stow all your correspondence. On the outside of the file, record any conversations you have with all affected parties and on the inside keep paper copies of all bills, letters and a copy of your certificate of coverage.
Next, try to work directly with the insurance company. Send them a letter stating your case, along with a copy of any denial you had received. In your letter, include you name, address, phone number and policy number. Specifically let them know what determination you are disputing (“You have denied us a referral to a speech therapist”) and why you are disputing this (“According to our pediatrician, Dr. Kelly Smith, a speech therapist will ensure that Junior will be properly prepared for Kindergarten”). Finally, let them know what you would like to see happen (“We would like a referral to ABC Therapy for 4 therapy sessions”).
Be sure to send your completed letter to your insurance company’s address and not a P. O. Box. You should be able to find their street address via their website. Also, send it certified mail to make sure that you have a paper trail of when it was received.
Allow approximately 10 days for a response. After that period of time if you have received either no response or another denial, it is time to move on to the next step. Every state has a Department of Insurance (DOI) that is committed to ensuring fair treatment of insured individuals within their state. To find the DOI in your state visit http://www.naic.org/state_web_map.htm. Once you locate the website for your local branch, search for terms like “complaints”, “grievances” or “consumer advocate”. Once you have found the link that can help you, work directly with the DOI to register a complaint against your insurance company and request swift action. This is where your file of all correspondence and phone calls will prove handy. The last thing an insurance company wants is a DOI complaint hanging over their heads and they are likely to suddenly be rather cooperative.
Written by Sue De La Bruere
