Health Insurance Articles
How To Appeal A Rejected Health Insurance Claim
2010-03-03
Insurance, in general, is a way for individuals or groups to protect themselves from the uncertainty of loss. Insurance is essentially a method of transferring an individual's or group's (insured or claimant) risk onto another entity (insurer) in return for periodic payments (premiums). The growing cost of care in the country today is revealing the need for health insurance coverage. Health insurance, though, like all insurance, requires underwriters to assess the claim in order to determine whether to accept or reject an application. Therefore, it is important to not only know the ins and outs of your policy once it is accepted, but also the procedures to appeal a rejected claim.
There are many types of health insurance and it is important to get the right policy for your situation. Asking an insurance agent for advice (which may cost you a small fee) or doing research to find the appropriate plan will most likely reduce the chance of an initial rejection as well as rejections of future claims. Finding the right health insurance plan and having your application accepted will significantly reduce the likelihood of rejections as the insurer is aware of existing conditions and potential claims, but the risk is still there.
Insurance companies are businesses like any other and their main goal is to reduce costs and maximize profits. It is not unusual for insurance companies to underpay a claim or simply reject it because, while insurance companies do aim to put the insured interests first, it would not always be profitable to do so. Often, a health insurance company will send the insured a form letter stating that they will not cover a particular procedure or drug. In many cases, if a health insurance claim is rejected, the claimant gives up rather than trying to challenge the insurance company. However, the insurance company is just as likely not to want a fight and in most cases will reverse an unjust decision.
While the exact course of action taken to appeal a rejected health insurance claim may vary with each state, the basic process is the same. Writing a letter to the insurance company and including documentation from a medical professional stating the reason for or need of the rejected procedure or drug is the first action. If the insurance is through an employer, send a copy of the letter to the appropriate personnel; they will most likely put additional pressure on the insurance company on your behalf. Keep all documentation and letters for your records and don't be afraid to be persistent. The only way for your case to be heard is to let the insurance company know about it.
