We’ve all heard the horror stories. A person has medical insurance, but the insurance company won’t pay for a critical test or procedure, and so the person dies or gets really sick. Usually, these horror stories come from activists and politicians that are trying to make a point about how they believe the medical insurance industry is “broken” or somehow otherwise defective.
Let’s sidestep that sticky issue for today, and focus on a practical matter. While it doesn’t happen very often, you need to know what you should do when your medical insurance company doesn’t want to pay for a particular claim.
The important thing is to act
Most folks just accept what the insurance company tells them. If the provider says “no, we won’t pay for that,” they accept their fate, throw their hands up in the air and say, “poor me.”
That is a big mistake.
You need to follow up. You can take just a few simple steps to get the claim reconsidered. In a good number of cases, simply doing this is enough to get the company to change their mind.
Identify the problem
If a claim is denied, the insurance company will usually give you a reason. In many cases, they will claim that the particular procedure, test or other medical service that you need isn’t covered by your policy.
If that’s the case, you need to read the policy. Look to see specifically what it is they’re referring to, so that you can identify where the problem is. Some things, like vision, dental and even pregnancy are just excluded from some policies. If that’s the case, you really don’t have much of a leg to stand on.
Human error
In other cases, though, the problem isn’t that you don’t have coverage. The problem is that there’s been a mistake somewhere. It might be that the health care provider entered the wrong billing code for your condition or treatment. It could be that someone at the insurance company made a mistake in reading the claim. There are plenty of points of failure, and working with your doctor’s office and the insurance company closely is the way to get those fixed.
While you can’t guarantee that a claim will be paid just because you ask for it to be reconsidered, you can guarantee that it won’t be paid if you don’t follow up.
Photo via aigarius
