How to appeal a health insurance claim

Appealing claims that are rejectedDistinguishing between accidents and illnesses in the emergency room

Sometimes you may disagree with your health insurance plan’s payment of benefits. This post teaches you how to appeal and where to turn when that happens.

Some health insurance plans attempt to control costs by refusing payment for emergency room care unless you first get permission from your doctor. Sometimes emergency room staff delays treatment while they check your insurance coverage. Legislation now establishes certain rights for emer­gency room patients, which minimizes these kinds of restric­tions. This post explains your rights to emergency room treatment under these laws.

If you object to the way your insurer paid your claim, start by calling your plan’s benefits administrator, if you have one, or check with your human resources department. If your objections are still unresolved, your next step is to file an appeal — a means of objecting to the way the insurer paid your claim and requesting the insurer to reconsider the claim.

Check your health insurance policy for a section on the appeals process. Your plan may spell out each step that you must follow to appeal your claim. Be aware of deadlines that you must meet to resubmit a claim, or you may lose your right to appeal.

Follow up on the response you receive from the insurer. Read it carefully and make sure that the insurer bases its decision on the correct information. If you discover that some of the infor­mation you submitted on your original claim is incorrect or inaccurate, notify the insurer in writing of the correction.

Mail correspondence by certified mail with a return receipt to confirm that the insurer received your letter.

If the insurer continues to deny benefits, submit copies of the claim, correspondence, notes, and the relevant pages of your policy to your state’s insurance department. Remember to include your policy or claim number. Write a cover letter explaining in detail why you think the insurer did not prop­erly pay benefits for your medical expenses.

The department of insurance notifies the insurance company of your complaint. The insurer must then respond to the state insurance department within a specified period, usually 10 to 30 days. After the insurance department receives the insurer’s response, it investigates and comes up with a solu­tion, if possible. Expect this process to take at least 30 days (longer if the case is complicated).

As you work through the appeals process, keep in mind that each state has its own laws — usually referred to as the Unfair Claims Settlement Practices Act — to protect you from unfair and deceptive practices in the insurance industry.

For more information on your particular state’s laws, contact your state’s insurance department. To find your state health insurance contact, check with the National Association of Insurance Commissioners.

Although the insurance protection laws differ from state to state, most of them have the following provisions in com­mon. The laws state that insurance companies

Must not intentionally misrepresent facts or provisions relating to coverage under your policy, such as stating that a condition is covered when it isn’t.Must acknowledge your claim and act promptly in response to your communications about your claim.Must put into action standards for timely investigation and processing of claims.Must not attempt to influence payment of a claim you make under one benefit provision (such as a hospital benefit) by delaying payment under another (such as a prescription drug benefit) when the amount the com­pany owes you is clear.Must not delay an investigation or payment of claims by asking you for reports or forms that are unnecessary or contain information that you’ve already submitted.Must not force you to file a lawsuit to recover money due under an insurance policy by offering you considerably less than the money ultimately recovered in a lawsuit.Must not, as a policy, appeal arbitration awards in your favor to force you to accept a settlement amount or com­promise for less than the amount awarded in arbitration. Both sides choose one independent third party, such as a judge or lawyer, to determine the outcome (arbitrate). The decision the arbitrator makes is usually final.Must not refuse to pay your claim or delay payment without conducting a reasonable investigation and giv­ing you a valid reason.

If you think that your insurance company is violating the Unfair Claims Practices Act, talk to a claims supervisor at the company and explain your concern. If that doesn’t help resolve your problem, file a complaint with your state’s insur­ance department.

The state insurance department can help only if the insur­ance company has broken the law. It can’t force the insurer to provide a benefit that isn’t in the health insurance policy. Many state insurance departments try to resolve the com­plaint by phone before the consumer resorts to filing a for­mal complaint.

If you hire a lawyer to resolve your complaint, the state insur­ance department won’t speak with you directly. As your legal representative, your lawyer speaks for you.

If their finding is against the insurance company, state insur­ance departments have the authority to impose penalties on an insurance company, ranging from assessing a fine to revok­ing the company’s state license.

The Emergency Medical Treatment and Active Labor Act of 1998 (EMTALA) states that hospitals must give appropriate care to people regardless of their ability to pay, including peo­ple whose health insurance coverage restricts emergency room benefits. Hospital staff can’t postpone examining a patient while checking on insurance coverage or while trying to get permission from a doctor in the patient’s health plan network to examine or treat the patient.

Individual state laws may offer rights in addition to the rights in EMTALA. Some states have a regulation that requires insur­ance companies to pay for emergency room care if a prudent layperson (a person with an average knowledge of health and medicine) acting reasonably would consider the situation a medical emergency.

Emergency room staff must do a medical exam before send­ing you to a clinic or doctor’s office. The exam determines whether you need immediate care and avoids putting your health at risk. If emergency room doctors determine that you have an emergency medical condition, they must stabilize or appropriately transfer you to another medical facility.

EMTALA defines an emergency medical condition as a medical condition with symptoms so severe that you could reasonably expect the lack of immediate medical attention to result in

Seriously jeopardizing a patient’s or unborn child’s health (in the case of a pregnant woman)Seriously harming any bodily functions or parts

When a pregnant woman is having contractions, EMTALA considers it an emergency when

There isn’t enough time to safely transfer the pregnant woman to another hospital before giving birthTransferring the pregnant woman may threaten her health or safety or the health or safety of the unborn child

If your condition doesn’t meet the definition of “emergency medical condition,” the hospital emergency room doesn’t have to treat you.