Tips to Follow When Your Health Insurance Doesn't Want To Pay

Many of us feel blessed because we are able to pay/qualify for Individual or Group Health Insurance.  

The story changes dramatically when a major health situation occurs and we find out the hard way that our policy (and sometimes our health company) is not as comprehensive as we had believed.

There are tips that you can follow (before or after something happens) that can help you determine whether your health insurance company is not covering a procedure because it is genuinely NOT covered by your policy or whether they're not covering it in the hope that you pay for it yourself. 

The first thing you should do is request a copy of your health insurance application. Why? because your answers in that application determine whether the insurance company can claim you concealed health information from them (and therefore your policy is VOID) or not. 

If they do void your policy it is a perfectly legal and retroactive move. In some situations all they have to do is refund your premium payments, others don't even get that back.  This is not what you want to hear when you're facing bypass surgery, dialisis or cancer diagnosis and you need your treatment to stay alive!

Second. Learn what your covered benefits are and their limits (if any).  A mostly unknown clause from a lot of policies is your out of pocket maximum. Typically this refers to services that qualify for co-insurance.  After your reach this (usually yearly) "Maximum" the insurance company is to pay 100% of your expenses that year. 

Find out and follow their internal Appeal process and document every call/letter regarding the uncovered bill(s). 

Have your doctor give you a letter outlining why this procedure is "medically necessary" AND the historical success rate of this procedure. Then, get a 2nd and even 3rd opinion (with letters) before submitting your appeal. 

Do not get wrapped in unreasonable time frames, if you need this procedure approved call/write/ email. Stay on top of the situation and have it go through their "expedited" processes.  If they're denying the claim, continue their internal appeal process or hire a Patient Advocate. 

Finally. Discuss your case with a reputable (and INDEPENDENT) Patient Advocate. Keep in mind that the "in house" Patient Advocate many hospitals/insurance companies have on staff may feel pressured to do what's best for the company.