By Mashum Mollah
Frequently, my insurance claim was denied that should be covered under policies in order to increase their bottom line, in hopes that the consumer won’t’ actually fight for the coverage they deserve because they believe that they have no recourse.
JG Winter, a brain injury lawyer, says that he has had many clients that have had this problem, which is why he knows exactly what to do if your insurance claim is denied. Thankfully, he has put it in writing for you to refer to if something like this ever happens to you. Here is what he says to do:
If you have a policy, know it.
Read your evidence of coverage (which is your contract with your insurance provider) and carefully assess how the plan could be interpreted in your favor or in your insurance provider’s favor. Be familiar with any appeals process.
Make sure you have the entire policy or coverage booklet and all of the endorsements. Now read them. Increasingly, these documents are written in a language an average person can follow. You will often find that your claim is covered under the policy for some reason which had not occurred to you.
If you don’t have these documents, the company must provide them.
Request An Explanation From Your Insurance Provider For Any Denial – And Get It In Writing:
Make the call. Some experts say that up to half of the claims initially rejected are paid upon review.
The Insurance Code requires that the company must give you the basis for the denial of your claim in writing. Demand that they do so and compare the reasons given with the policy or coverage booklet.
Often the solution to your problem will become obvious at this point. Many errors are corrected at this stage by, for example, providing a letter from your doctor or other evidence which might cause the claims adjuster to change his or her mind.
The company must provide you with any personal information, like lab tests or medical records, they relied on in denying your claim.
Carefully Document Everything:
Good notes help you remember what was said, will aid anyone who tries to help you, and can be used to support your case in the event you need legal assistance.
Keep notes of each telephone conversation or other contact you have with the people working on your claim. Keep track of the date, time, identity, and title of each person involved.
This will avoid having to tell the story twice, personalizes your case, and helps make sure you’re speaking with someone who has the power to help you.
Always keep correspondence and put your communications in writing so the company cannot ignore you or pretend that you have not pressed your claim. If you are given an “opinion,” request that it be provided in writing. Follow up all oral contacts with the company with a letter (“As we discussed today…”).
Send everything by certified mail. This will avoid the possibility of a company saying the correspondence was not received.
Educate Yourself About Your Condition:
Ask your doctor(s) for support and assistance. Don’t be shy. A denial may be something as simple as an incorrect medical code assigned to your file.
Request your doctor write a letter for you explaining why the claim should be covered, or why the company’s reason for denying the claim is incorrect.
Remember:
- State your questions/requests clearly and concisely; don’t allow a misunderstanding to come between you and what you want.
- Stick to the subject at hand; no one cares about what happened during your Aunt Tilly’s operation.
- Remain firm, don’t be intimidated. If your claim has been rejected, you have a right to find out why.
