by Kantor & Kantor, LLP
Challenge
# 1: Understanding your policy
# 1: Understanding your policy
Navigating
through your policy, or simply sifting through documents from your insurance
company, can be very tedious — and even more so when you do not understand the
“language.” Becoming familiar with your policy can help you
understand commonly used insurance terms and strengthen your proficiency when
communicating with insurance companies. Before you can begin advocating for the
health benefits that you are entitled to, you must have a copy of your
insurance policy. Ask your employer or insurance company to send you a Summary
Plan Description and all Benefit Plans provided by your employer. You should
know that upon written request, your employer (or the Plan Administrator) is
obligated under Federal Law to provide you with information regarding benefit
programs within 30 days. Know your policy: without it, you don’t know the
rules!
through your policy, or simply sifting through documents from your insurance
company, can be very tedious — and even more so when you do not understand the
“language.” Becoming familiar with your policy can help you
understand commonly used insurance terms and strengthen your proficiency when
communicating with insurance companies. Before you can begin advocating for the
health benefits that you are entitled to, you must have a copy of your
insurance policy. Ask your employer or insurance company to send you a Summary
Plan Description and all Benefit Plans provided by your employer. You should
know that upon written request, your employer (or the Plan Administrator) is
obligated under Federal Law to provide you with information regarding benefit
programs within 30 days. Know your policy: without it, you don’t know the
rules!
Plenty of people have difficulty interpreting the terms of their policy. It is
not uncommon for our clients to seek our advice in making a claim or appeal to
their insurance company.
Challenge
# 2: Communicating with insurance companies
# 2: Communicating with insurance companies
Better
Homes and Gardens (BHG) conducted a survey of over 1,000 women across the
country. They found many survey respondents to be intimidated simply by the
thought of contacting their insurers. 44% of these participants confessed they
lacked confidence in communicating effectively with insurance companies, and
76% said they desired to learn how to properly communicate with their insurer.
At Kantor & Kantor,
we understand how challenging and overwhelming the prospect of trying to get
answers from your insurance company can be. We advise that you try to stay off
the phone as much as possible! All communication should be in writing, in
traceable forms such as certified mail, fax or e-mail. If you can’t prove it,
it never happened! Although it’s not always possible, while you are on the
phone try to get the name, title, phone number and email address of everyone
you talk to. Speaking with different insurance representatives can become
confusing and overwhelming. Keep a journal of your conversations so that you
can refer back to them later.
Homes and Gardens (BHG) conducted a survey of over 1,000 women across the
country. They found many survey respondents to be intimidated simply by the
thought of contacting their insurers. 44% of these participants confessed they
lacked confidence in communicating effectively with insurance companies, and
76% said they desired to learn how to properly communicate with their insurer.
At Kantor & Kantor,
we understand how challenging and overwhelming the prospect of trying to get
answers from your insurance company can be. We advise that you try to stay off
the phone as much as possible! All communication should be in writing, in
traceable forms such as certified mail, fax or e-mail. If you can’t prove it,
it never happened! Although it’s not always possible, while you are on the
phone try to get the name, title, phone number and email address of everyone
you talk to. Speaking with different insurance representatives can become
confusing and overwhelming. Keep a journal of your conversations so that you
can refer back to them later.
Challenge
# 3: Filing Appeals when coverage is denied
# 3: Filing Appeals when coverage is denied
30 % of
the BHG survey participants reported that they have been billed for something
that they believed should have been covered. Sadly, many people who fall into
this category end up paying the insurance company without a fight. For
instance, 57% of participants said that they would not know how to appeal a
coverage denial, and 23% of participants said that they have actually ducked
the appeal process because it seemed too complicated. The appeal process is
complicated, but it is often worth the effort! Former Insurance Executive Lisa
Zamosky (author of Healthcare, Insurance, and You) said that more than half of
all appeals are decided in the insured’s favor. Below are a few simple tips to
help make you more familiar and comfortable with the appeal process, in the
event that your health insurance claim is unfairly denied. Our hope is that
having this information readily available to consumers will make the appeal process
seem a little less complicated, and a little bit more approachable and
manageable.
the BHG survey participants reported that they have been billed for something
that they believed should have been covered. Sadly, many people who fall into
this category end up paying the insurance company without a fight. For
instance, 57% of participants said that they would not know how to appeal a
coverage denial, and 23% of participants said that they have actually ducked
the appeal process because it seemed too complicated. The appeal process is
complicated, but it is often worth the effort! Former Insurance Executive Lisa
Zamosky (author of Healthcare, Insurance, and You) said that more than half of
all appeals are decided in the insured’s favor. Below are a few simple tips to
help make you more familiar and comfortable with the appeal process, in the
event that your health insurance claim is unfairly denied. Our hope is that
having this information readily available to consumers will make the appeal process
seem a little less complicated, and a little bit more approachable and
manageable.
1. The
Process
Process
Before
initiating the appeal process, request your claim file and policy from your
insurance carrier or employer. You will need to review your policy. Consider
what evidence you have to prove that this coverage is medically necessary, and
include this in your appeal packet. Remember that if you have an ERISA
(Employee Retirement Income Security Act) governed policy, once a decision is
made on your final appeal, your file is closed. Any information you leave out
may never be heard or considered by a court!
initiating the appeal process, request your claim file and policy from your
insurance carrier or employer. You will need to review your policy. Consider
what evidence you have to prove that this coverage is medically necessary, and
include this in your appeal packet. Remember that if you have an ERISA
(Employee Retirement Income Security Act) governed policy, once a decision is
made on your final appeal, your file is closed. Any information you leave out
may never be heard or considered by a court!
2. Your
Policy
Policy
“Your
policy is a contract,” says Cofounder of Health Advocate Martin Rosen.
“The more you know, the better case you can make.” If you need help
interpreting the language of your policy, do not hesitate to contact an expert.
Kantor & Kantor
offers no-cost consultations, and can offer support when appealing a health,
disability, or long term care insurance denial.
policy is a contract,” says Cofounder of Health Advocate Martin Rosen.
“The more you know, the better case you can make.” If you need help
interpreting the language of your policy, do not hesitate to contact an expert.
Kantor & Kantor
offers no-cost consultations, and can offer support when appealing a health,
disability, or long term care insurance denial.
3. How
To Write An Appeal Letter
To Write An Appeal Letter
Your
appeal letter should read like a cover letter to your insurance company. Refer
to the evidence and documents enclosed in your appeal packet, and indicate why
this information should change their mind. Although appeal letters vary in
style, the format of your letter should include the following: First, simply
state that you are appealing the decision. Next, explain why you disagree with
the decision. Finally, provide support to your claim. Take this opportunity to
explain the history of your health condition and treatment, including side
effects of any medications, and the full impact the illness has had on your
life. In your letter, consider including:
appeal letter should read like a cover letter to your insurance company. Refer
to the evidence and documents enclosed in your appeal packet, and indicate why
this information should change their mind. Although appeal letters vary in
style, the format of your letter should include the following: First, simply
state that you are appealing the decision. Next, explain why you disagree with
the decision. Finally, provide support to your claim. Take this opportunity to
explain the history of your health condition and treatment, including side
effects of any medications, and the full impact the illness has had on your
life. In your letter, consider including:
-Summarize
any prior letters or documents
any prior letters or documents
-Point
out the inconsistencies in your insurer’s decision
out the inconsistencies in your insurer’s decision
-Point
out the irregularities in your insurer’s decision
out the irregularities in your insurer’s decision
-Point
out the omissions in your insurer’s decision
out the omissions in your insurer’s decision
-Enclose
any new documents
any new documents
4.
Gather and Include Evidence
Gather and Include Evidence
Include
copies of all medical records. Remember to keep copies of all out-of-pocket
expenses for future reimbursement.
copies of all medical records. Remember to keep copies of all out-of-pocket
expenses for future reimbursement.
5. Get
Written Support From Your Doctor, Family, and Friends, and Co-Workers
Written Support From Your Doctor, Family, and Friends, and Co-Workers
Letters
from providers and family members can be a powerful way to display how your
illness has impacted your life. Be as thorough as possible so that you can
transmit the full picture to the insurance company.
from providers and family members can be a powerful way to display how your
illness has impacted your life. Be as thorough as possible so that you can
transmit the full picture to the insurance company.
6.
Understand That A Denial Is Not The Final Word
Understand That A Denial Is Not The Final Word
A
denial by your insurance company is not the final word. With a little advocacy,
research, and determination, you will have the tools to fight for the health
benefits to which you are entitled. For some, it might be possible to overturn
a denial without legal assistance. If a case becomes too complex to manage on
your own, you may want to consider seeking assistance from a reputable
professional.
denial by your insurance company is not the final word. With a little advocacy,
research, and determination, you will have the tools to fight for the health
benefits to which you are entitled. For some, it might be possible to overturn
a denial without legal assistance. If a case becomes too complex to manage on
your own, you may want to consider seeking assistance from a reputable
professional.
Kantor & Kantor is one
of the most experienced and highly respected law firms dealing with the
prosecution of claims against insurance companies. We represent clients whose
insurance companies have failed or refused to pay claims arising out of
Disability, Health, Life, Long Term Care and other liability insurance claims.
of the most experienced and highly respected law firms dealing with the
prosecution of claims against insurance companies. We represent clients whose
insurance companies have failed or refused to pay claims arising out of
Disability, Health, Life, Long Term Care and other liability insurance claims.
..
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