They are words we hope we’ll never hear: “your health insurance claim is denied.” It happens, though – millions of times each year. Sometimes a denial is legitimate – the treatment truly is not covered by the insurance policy. But at other times the claim was denied in error.
A recent study by the Kaiser Family Foundation revealed that, when faced with a denied health claim, fewer than one percent of consumers appeal.* The study did not explore why consumers don’t appeal. It is likely that sometimes they don’t appeal because they are so busy dealing with all their health problems and don’t have the energy to deal with it. In addition, I can imagine that consumers may be intimidated by the complexity of the insurance world; I can also imagine some people may not even realize that appealing is an option.
When I read how few people appeal, I was concerned. I want consumers to know they can appeal, and that they should appeal if they believe a medical treatment should have been covered by their policy. NOTE: insurance companies generally allow a specific window of time in which to appeal – probably 2-4 months – so try to deal with it fairly speedily.
Knowing you have the right to appeal is the first step. Contacting the insurance company to request a written statement explaining the reason for denial is step two.
From there, options vary. You may be able to enlist support from your medical provider to justify the medical necessity or clear up any coding errors. Beyond that, ask the insurance company to outline its appeal process, and follow it carefully, keeping copies of all correspondence. If your appeal is denied by the company, ask about an external appeal process — some types of plans include provisions for external review.
If you are not satisfied with how your appeal is handled, consider a complaint through the Iowa Insurance Division. ISU Extension’s Iowa Concern Hotline (800-447-1985) is another resource when you don’t know what steps to take next; their staff attorney provides legal education and may be able to help you identify additional options.
*Note: the data used in the KFF study was limited to plans offered through the healthcare.gov Marketplace; it is possible that appeals rates might be different for other plans, including employer-sponsored plans.