If you have health insurance through your employment, your benefits are governed by the Employee Retirement Income Security Act (ERISA). There are very specific steps you have to take in order to ensure your entire claim for health insurance benefits are paid. If some or all of your claim is denied, you are obligated to timely appeal the denial. The time period in which to appeal the decision is stated in your health benefit plan, but usually you will have thirty to sixty days to submit an appeal.
Filing an appeal to your health plan does not guarantee the claim will be paid. However, the appeal is very important because it creates the only record and documentary evidence upon which you can base any lawsuit if your appeal is denied. That means that any information you want to present in a lawsuit must be included in your appeal.
Review your health plan and know the details of your insurer’s appeals process. The summary of benefits and the plan document contain all of the tools needed to properly make an appeal, including the deadlines. If you miss a deadline, you waive your right to appeal or file suit to reverse the claim denial.
Get your entire claim file. You can’t put together a puzzle without all the pieces. Request a copy of your claim file and the plan/policy from your employer or insurance carrier before submitting an appeal. The claim file should include all medical records reviewed, internal notes and memoranda, and possibly outside doctor or nurse evaluations.
Get written help from your treating doctor. Read the policy and the grounds for the claim denial and ask your doctor to write a letter refuting the basis for the denial. This usually means your doctor will write a letter explaining the medical care was “medically necessary” or not to treat a pre-existing condition that might otherwise be excluded. If the denial is based upon the treatment being considered “experimental”, then have your doctor provide you with resources supporting the application of the medical therapy to the illness or condition.
Take detailed notes when you speak with your insurance company. Write down the date and time, the length of the call, the name of the person with whom you spoke, their title and all of the details of the conversation.
Write down your argument. Make notes of exactly what happened, when and why. Refer to your medical records and other documentation in making your argument. If you are seeking approval for future treatment, write down any supporting science, clinical evidence, or expected benefits. Be as comprehensive as possible because this is the only documentation and evidence you will have for this appeal. If the issues are confusing to you, hire a lawyer to help you write the appeal.
Follow up with your insurance company. Most appeals take weeks or months. Call often to check on the status and take notes of each call.
If your appeal is denied, call an ERISA lawyer to file an ERISA suit in federal court.
What NOT to do when appealing a claim denial
- DO NOT send in your appeal before reviewing your claim file and policy.
- DO NOT submit your appeal with just a letter written by yourself. You are not a medical expert! Present your appeal with supporting documentation from your medical records, your doctor’s letter and supporting medical journals or articles.
- DO NOT send your appeal documents be regular mail. Send it in as certified mail, return receipt requested. Try to make all communication with the insurer in writing, email or fax and not by phone.
- DO NOT miss the deadline to appeal. Failure to appeal before the deadline means you waive your right to pursue the claim any further.