How To Handle a Denied Health Claim

There are several ways to go about handling a denied health claim and honestly, not all of them involve legal help.

You need to know you’re dealing with a contract. It’s between two parties, you and the health insurance company. In most instances this contract gives you a good idea of what coverage you have (procedures covered), how much of the bill the insurance company pays and what services are covered.

Here’s a quick example of how that may work. Let’s say your Preferred Provider Organization (PPO) covers a visit to a doctor in the network with a $50 co-pay. If you choose to go to a doctor outside the network, the PPO may only agree to pay 50% of the physician’s bill.

In the case of prescriptions, the plan may cover 100% of your meds if they were prescribed in a network hospital. If on the other hand you choose to buy meds at a drugstore, they may only offer to cover 50% of the value of the drugs, after you’ve paid a high deductible.

You already know how convoluted health coverage can be, so make it a point to read your health care policy. As boring as it may seem, the information in it may save you time and money later if you have a dispute with your insurer.

Keep in mind that although your doctor may think you need a certain procedure, you may find your plan doesn’t cover it. In other words, it’s not in your contract with the health insurance provider. This is yet another reason for you to know what your coverage actually “covers.”

Even knowing your policy won’t guarantee you don’t have a claim denied. It’s like death and taxes, almost inevitable. However, there are things you are able to do for yourself before you contact an attorney.

Do the obvious first – call customer service and find out if they denied your claim because of a medical coding error. That happens fairly frequently. If it wasn’t a coding error, then attempt to get an explanation. Here’s where things get a bit sticky.

If you honestly believe the insurer did stick to the terms of the policy, pay the bill. If on the other hand you think they’re waffling and aren’t living up to their part of the bargain – this now becomes a dispute and you need information on the arbitration process.

Take time to call your state insurance department as well. They may be able to resolve things for you, IF your insurer did break any regulations. If you don’t get any satisfaction and feel like you are getting a huge run around, contact an attorney with experience in settling and/or litigating health care disputes.

If the insurance company is trying to get you to settle for a smaller claim, or none at all; are asking for excessive documentation/verification of your claim or telling you to resubmit what you have already provided, speak to a competent lawyer who will assist you to cut through the red tape and get the matter resolved.

Lance Sharp of The Sharp Firm is an Austin personal injury lawyer specializing in personal injury and accident law in Austin Texas. The lawyers at The Sharp Firm have a collective 40 years experience in being Austin injury lawyers. To learn more visit http://www.sharpfirm.com.

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