NCPA - National Center for Policy Analysis


September 12, 2005

Many individuals whose claims are denied by their health insurance plans think they don't have a second chance in getting their claims paid. But in fact, 70 percent of claims appeals are successful, says Jennifer Jaff, author of "Know Your Rights: A Patient Handbook for Chronic Illness."

What can a patient do to improve his or her chances of getting claims paid by a health insurer?

  • Ask for documentation from the health insurer that might support the reason for the claim denial.
  • Ask the doctor to write a letter on the patient's behalf, including a brief medical history and explanation as to why the medical treatment in question is necessary.
  • Keep detailed records; use a spreadsheet or software program, such as Quicken Medical Expense Manager.
  • Pay attention to deadlines set by the insurance company regarding the time allowed to file an appeal.

If all else fails, patients can ask for a review. Currently 43 states and the District of Columbia have independent boards to review denials of health insurance claims. State programs cover employer-sponsored insurance plans and private plans. However, company self-funded plans are ineligible.

Filing a lawsuit should be the last resort, says Jaff. The federal Employee Income Retirement Security Act requires claimants to show that the insurer's decision was "arbitrary and capricious," which makes such lawsuits hard to win.

Source: Sandra Block, "Don't Take it Lying Down if Your Insurer Refuses to Pay," USA Today, September 2, 2005.

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