Rejected health insurance claims are frustrating and stressful. It takes a massive financial toll on you and your family when your insurance refuses to cover a medical expense. Thankfully, you can appeal the claim, and even have legal options for you if your claim is rejected.
First, find out if the claim was denied or rejected. Rejected claims don’t need to be appealed. A rejection means that the claim has been filed with incorrect information, or a mistake was made by a claims agent. If you have a rejected claim, all you need to do is resubmit the claim with the correct information. When revisiting your claim, look out for:
- Any incomplete or incorrect information or misspellings.
- Whether or not your health insurance plan covers the claim.
- If you’re still within your insurance limits.
- Claims with a healthcare professionals outside your network or that need a referral.
- Any products paid for by insurance aren’t replaceable due to ill-care.
If you’re still having trouble finding the problem with your rejected claim, ask your insurance provider what’s missing from the report.
If your claim was denied, your insurance company will send a letter with an explanation. This letter explains exactly which claim is denied and why. Finding out why the claim was denied before you appeal the claim will also let you know if there was a filing or clerical mistakes by your claims agent.
It’s also important that you understand why the claim was denied. Your appeal will be reviewed much more quickly. Ask or search on your insurance company’s website to see how to make an appeal.
The claims must be in your network and within all your limits. Double check what your network and coverage limits before any future healthcare visits. If you have gone over your limit, you can negotiate an out-of-pocket payment plan with your insurance company.
What Happens If You Go Over Your Policy
Go over your policy and highlight everything that may be relevant to your claim. Working with a lawyer can also help you know what’s covered.
First, Write down everything that is covered by your insurance, and make copies of the policy with your annotations. Your insurance company is obligated to ensure you understand everything that is and isn’t covered. Next, note anything that seems too vague and ambiguous, then talk with your lawyer about the implications of those statements.
If your insurance company has not answered all questions regarding your policy truthfully and honestly, they cannot reject the claim. Finally, send one of the annotated copies in your letter of appeal, and keep one for your records.
Making The Appeal
Get in contact with the claims agent handling your case, or call your insurance company’s claims department. Then find out who the appeal should be sent to and how long their appeal process normally takes. A lawyer can also help you write your appeal letter.
In your letter, be sure to include the following:
- An opening statement with your policy number and claim.
- Any rejected claims and evidence related to it.
- An explanation with your medical history and conditions.
- Why these procedures are essential.
- Your annotated policy with a list of everything that should be covered.
- Supporting evidence from your doctors.
Make sure to have several copies of the appeal letter for you and your lawyer. Having a lawyer help you write the appeal letter will also ensure that everything is accurately covered.
If Your Appeal Is Denied
If your insurance company replies with a vague or unclear response regarding the terms of your policy, contact a lawyer if you have not already. Insurance companies must be truthful and honest about their policies.
A lawyer can help you navigate all the falsities and failures of your insurance company. Call My Case Helper to talk to one of our Premier Partners about what you can do about denied claims.