Many of us have had this happen before: your health insurance gladly accepts your monthly premiums, but when it is time for them to cover a major health cost (for example, a surgery), they delay coverage, deny payment or don't cover as much as you thought they would. The process of trying to fight it then becomes extremely frustrating and full of delay, representatives of your insurer often not having any answers, referring you to someone else to call, who then refers you back to the department you already talked to. They literally send you in circles.
This process is deliberately frustrating and intentionally set up with the hopes you will simply give up. In fact, often times insurers are blatantly violating the terms of your policy because they know you haven't read it, they know you won't read it and that if they cause enough frustration, you will eventually accept their decision and go away.
Here are some tips that will arm you for this fight.
1. Read and know your policy
Policies often define very clearly what your insurer will cover and how much time your insurer has to make a claims decision. If an insurer denies your claim or limits the coverage, the policy often requires them to lay out in writing, in detail the exact basis for their denial and the exact policy language they relied on in making the determination.
If you haven't read the policy, you won't know if your insurer is violating their own agreement and obligation to you. As I already mentioned, insurers often do violate the agreement because they know you probably haven't read it. Making your insurer aware you have read it and citing the exact section of the policy they are violating--letting them know they have blown their deadline in making a decision or that they haven't sent you their decision in writing as required, for example--will put them on notice you are on to them. They will take you more seriously.
Many people think a denial of the claim is the end of the road for them, but this is not true. In fact, most policies give insureds the right to appeal the insurer's decision more than one time, and then take your claim to the courts if that fails. Of course, most people don't know their rights because they don't take the time to follow Tip #1.
If you don't agree with your insurer's decision, read the appeals process of your policy and carefully follow the instructions it gives you. Many times there is a small window to appeal, so don't put it off--act quickly. If the policy gives you the right to appeal more than once, exercise that right. Oftentimes if the insurer is violating their agreement with you, the appeals process will correct it. 3.
If the appeals process doesn't work out, most policies give you the right to bring the matter to the court, suing for breach of contract and, depending on the type of policy, insurance bad faith. The threat of litigation will cost your health insurance more money, because they will have to pay an attorney to defend their decision, and might have to pay more than just the benefits of your coverage if they lose. Your health insurance company may just decide that covering you for your treatment is better than what they will have to pay a lawyer to fight it, as well as the risk of what they will have to pay if they lose.
Remember: If you've made it this far, you've taken the process way further than the majority of people, most of whom gave up long before now. An insurer's system is designed around saving money by relying on people who give up--if you remain patient and see the process to the end, you are costing the insurance company money they were trying to save and going against the grain of how the system is set up.
4. Tell them you will take your business somewhere else
This used to be an empty threat in many situations. For example, before Obamacare, if you had a pre-existing condition many insurers knew you were stuck with them because no one else would accept you if you went somewhere else. With the new healthcare system and more options for consumers, however, your threat to get insurance elsewhere might just change their mind.