| A health insurance policy is a contract between | | | | get the issue resolved at this level first. If no |
| you and your medical plan company. It outlines | | | | error has been made, make sure you understand |
| the medical procedures that are covered, what | | | | why your own medical plan denied the claim. If |
| portion of a bill the insurer will pay, and under | | | | you believe your insurer stuck to the terms of |
| what circumstances services are covered. For | | | | the policy, then you probably need to accept the |
| instance, a PPO plan may cover an in-network | | | | bill. However, if you believe the insurer did not |
| doctor's visit with a $40 copay, but only pay 50% | | | | follow the terms of the contract then you have |
| of the doctor's bill if you choose to find a | | | | just begun the dispute process. |
| physician out of the network. They may cover | | | | - Find out your health plan's arbitration process. |
| 100% of medication which is prescribed in a | | | | This should be outlined in the brochure that came |
| network hospital, but only cover 50% of | | | | with your own policy, If you do not have the |
| medication, after a $500 deductible, which are | | | | brochure or booklet, get the information from |
| purchased in a drug store. These are just | | | | customer service. |
| examples, and are not meant to outline the | | | | - Contact your own state's insurance department. |
| coverage of any particular medical plan. The point | | | | Sometimes they can step in and resolve the |
| here, is that health coverage can be complex, and | | | | claim. However, they will only be effective is your |
| it is important to take the time to understand you | | | | insurer broke any of your state insurance |
| own personal policy. | | | | department's regulations. |
| Another point to consider is that just because a | | | | - Get a lawyer. Because lawyers are expensive, |
| doctor determines that you need a particular | | | | and because they cannot assure you will prevail, |
| medical procedure does not mean that your plan | | | | this should be a last step unless your situation is |
| covers it. Understand that there is a difference | | | | very urgent. Some lawyers will work on a |
| between your own contract with an insurer and | | | | contingency basis, where they only collect if you |
| what a doctor thinks you need. You also cannot | | | | win the case. Your initial consultation should be |
| expect your own physician to be familiar with | | | | free, and that is the time when the lawyer can |
| every single medical plan his patients have. Many | | | | tell you if you have a good case. |
| doctors will try to work with the coverage you | | | | Understand your medical plan before you need to |
| have, but they can only do that if you help them. | | | | use it. Try to help you doctor understand what is |
| So we all know that insurance companies do deny | | | | covered. If you do have a problem, try to |
| claims. If you believe that you should be covered, | | | | resolve it with the health insurance company first |
| it is your responsibility to dispute that claim. Here | | | | because this process does solve many problems. |
| are the steps that we think you should take. | | | | If that doesn't work the state insurance |
| - Call customer service first. We have found | | | | department and the laws of your state are put in |
| many examples of medical claims being denied | | | | place to protect you. |
| because of a medical coding error. See if you can | | | | |