Personal Injury Care Line

Battling an Unfair Health Insurance Claim Can Really Pay Off

Are you having trouble getting your insurance company to pay your medical health costs? Join the club. When managed care entered the insurance scene a decade ago, its mandate was to contain rising medical costs. One way to do that is to deny claims, even when claims are legitimate. The consumer backlash led to many states establishing independent review panels and requiring insurance companies to develop in-house appeal procedures. Forty-two states now have independent review boards whose decisions can override those of insurance companies. Most consumers don’t even realize these review boards exist.

Another problem is that too many people just give up when their insurance claim is denied initially. The appeals process can be long and frustrating and many people don’t have the patience or time to pursue a claim no matter how legitimate. People must be persistent and they can win. Particularly if there’s substantial money involved, the time you dedicate to appealing insurance company decisions can pay off usually more quickly than you think. A Kaiser Family Foundation study recently found that 52% of patients won their first appeal for each claim made. The insurance companies aren’t getting with out paying anymore.

If your first appeal gets turned down, press on. The study found that those who appealed a second time won 44% of the time. Those who appealed a third time won in 45% of cases. Which means the odds are in your favor no matter how long it take. Remember that every time you appeal it costs the insurance company more money to fight you and they are not only going to lose money to you, but also in court costs. Medical health benefits are particularly tricky because insurance companies usually have a cap on the amount of money they’ll spend in a given year, or on the amount of visits they’ll pay for. But there’s often some flexibility when you can document that you or your child’s health warrants more care than your policy usually covers. Here’s how to get started:

Do Your Homework

Read your Policy: What are the benefits? Which kinds of services are included? Outpatient or inpatient care? Is it a serious or “non-serious” diagnosis?

Know the law: Contact your local Health Association to determine your states legal requirements regarding insurance payments for all illness. Does your state require full or partial parity? Are parity benefits available only to patients with “Serious Illness” or is a so-called non-serious illness also included?

Provide written documentation: Some insurance companies may not consider some diagnosis’s serious. In this case, you will need documentation to validate required services. Obtain a letter of medical necessity from your doctor and get test results showing the medical need for you or your child to receive certain services, based on the diagnosis.

Keep good records: Remember, you’ll be dealing with a bureaucracy. Keep the names and numbers of everyone with whom you speak, the dates on which you spoke, and what transpired in the conversation.

Start early: If you can, start the appeals process prior to initiating treatment. If the doctor says your child will need to be seen once a week for a year, begin immediately to appeal your insurance company’s policy of reimbursing only 20 visits a year.

Call and Ask the Insurance Company:

What are the prerequisites for receiving health benefits?

How many visits are allowed annually for you or your child’s diagnosis? Can multiple services be combined on one day and be counted as only one day or one visit?

Which services must be pre-certified–by whom?

Be positive, polite and patient with the customer service representative. Remember that he/she is only the messenger, not the decision-maker. They are the gatekeepers and can either provide you with access to a decision maker or make your life miserable, depending on how you interact with them.

Be persistent. There are no magic bullets. Be like a dog with a bone and don’t give up until you get the answer you want. If you get nowhere after several calls, ask for a supervisor or a nurse in the pre-certification department.

Remember that you do have the right to appeal if your claim is denied. Most consumers get discouraged and will not continue to pursue a claim that should or could be paid. Insurance companies count on that happening, so get out there and claim what’s justifiably belong to you.

Health Insurance It’s Important To Know What’s Not Insured!

Around 7 million people in the UK are covered by health insurance, the majority being covered through their employers. The problem is that few have really studied their policy documents and many misunderstand what is covered. And perhaps just as important, what isn’t. If you expect health insurance to pay all your health costs, you’re mistaken.

Health insurance is designed to provide protection for curable, short-term health problems and allow policyholders to jump the NHS queues to see consultants, be diagnosed, receive surgery or be treated. That sounds fine, but before you buy you need to appreciate the treatments and situations that fall outside the scope of the cover.

But first a word of warning. This article does not relate to any specific policy and the terms and conditions issued by individual insurers do vary. So please ensure you also check your policy documents. After reading this article, you’ll know what to look out for!

Sorry it’s a chronic condition

If a condition can be cured and is not a long-term problem, your insurance company will classify it as acute and should meet the cost. If your problem is incurable or it’s a problem that, despite appropriate treatment, will be with you for a long time, then your insurance company will classify it as chronic – and no, you won’t be covered.

But drawing a firm line between what is acute and what is chronic is fraught with problems, and leads to the biggest area of conflict between insurer and policyholder.

Everyone agrees that diabetes and asthma are chronic conditions as you’re likely to suffer from them for the rest of your life. So those sorts of condition are not covered.

Problems arise when the medical team initially considers a patients’ illness to be curable, but the condition subsequently deteriorates and the doctors change their mind, it’s now become incurable. This can happen especially in the treatment of some types of cancer.

In these circumstances, the condition is initially defined as acute and is therefore insured, but deteriorates and becomes chronic – and outside the terms of cover. This is possible as insurers retain the right to reclassify a condition from acute to chronic during treatment.

Sorry – it’s too long term
The insurance company will not pay out for long term treatment. But you need to check your policy documents to see how they define long-term. You can find the situation where a course of drugs extends for say 12 months, but the insurer will only pay for ten months.

Sorry it’s preventative
Your insurance is designed to pay for the treatment and cure of conditions when they arise. It is not designed to pay for treatments that are used to prevent an illness.

Again, the problem of definition arises. Sometimes it is arguable whether a treatment is preventative or a cure. Take the drug Herceptin for example. This drug can be used in the early stages of breast cancer. Research shows that Herceptin can halve the incidence of cancer returning for women who have a particularly virulent form of the cancer known as HER2. In this situation, is Herceptin offering a cure or is it a preventative?

Insurance companies are split on the debate. Norwich Union, WPA, BUPA and Standard Life Healthcare will pay for Herceptin for HER2 patients whereas Legal and General and Axa PPP will not.

Sorry the drug is not approved
Two of the main attractions for taking out health insurance are: to jump the queues at the NHS, and to get the latest treatments and drugs. But there’s a rider.

Unless the drug has been approved for use by the NHS in England and Wales, by the Institute for Health and Clinical Excellence, your insurer is unlikely to approve its use. The problem is that the Institute’s brief is not simply to decide whether a drug works, but to carry out a cost/benefit analysis to ensure that the benefits to the nation outweigh the financial costs of using it in the NHS. Not an easy brief – and one that has placed the Institute under scrutiny for the extended delays in drug approval.

The compromise hit on by the Financial Ombudsman is that if a health policy won’t pay for the use of experimental treatments, then it should meet the cost of an approved conventional treatment with the policyholder footing the bill for the balance if the experimental treatment is more expensive.

Sorry it’s a pre-existing condition

The basic principle is that if you are already suffering from a condition when you start a policy, then that condition pre-exists the policy and any claims for its treatment are invalid.

For this reason, insurance companies insist you complete an exhaustive questionnaire before they agree to insure you. After all they need a clear picture of your medical condition before they quote. For many applications, the insurer will, with your approval, also write to your GP for specific details of your medical history. They like to have a complete picture.

So lets say some years ago you injured your knee playing football. It appeared to recover but now it turns out that you have a torn cartilage and need an operation. The insurer could argue that this is a pre-existing condition and you have to pay for its’ treatment.

Some insurers try to accommodate these grey areas with a moratorium provision within your policy. These provisions typically say that so long as you have been symptom free for two years relating to any condition you’ve suffered from within the last 5 years, then they will pay for subsequent treatment. Not all policies have these moratorium provisions and the time periods do vary between insurers. You should carefully read your policy.

Sorry its not covered

Health Insurance is an annual contract just like your car insurance. So when it comes to renewal, your insurer is at liberty to review not only your premium but also change the conditions on which your cover is provided.

Therefore, if your policy comes up for renewal mid way through a course of treatment, it’s possible to find that your new policy no longer covers that particular treatment. This means that you will have to foot the bill for the balance of the treatment.

Furthermore, with ongoing advances in medical research, more and more conditions are becoming treatable. This progress has the effect of shifting back the dividing line between chronic and acute conditions.

This hits the insurers’ pocket in two ways. With more conditions being reclassified as acute, the number of claims is increasing. And there’s also a trend for new treatments to cost more Herceptin being a good example. The net result is that the insurers are finding themselves having to pay out far more. This is inevitably passed back to you through increased renewal premiums. And in an attempt to reduce their risk exposure, insurers have a tendency to adjust their definitions and exclusions. This means that you must read your renewal notice closely before you decide to renew.

So when you are considering Health Insurance, be aware that everything is not always black and white. And if you’ve got insurance and need treatment, always contact your insurer without delay and get them to confirm that your treatment is indeed covered

Nearly 70 percent of older Americans endorse the concept of individual health savings accounts to help cover medical expenses in their later years, a new survey finds.

The accounts would involve setting aside 1 percent of income to handle expenses not covered by Medicare, the federal insurance program for people aged 65 or older.

The survey also found that a majority of those interviewed expressed support for being able to buy into Medicare before they turn 65.

It Won’t Be Easy Without Health Insurance

Many older Americans are facing a bleak picture as they enter retirement. Not only do they often struggle with chronic health problems, but their wages are stagnant, health costs are rising and retiree health benefits are declining.

Fifty-three percent of respondents who worked or had a working spouse said they would not have job-based health benefits when they retired. According to researchers, 12 million older adults are currently uninsured or have had histories of unstable coverage.

It Takes Money To Have Health Insurance

Twenty-four percent of adults aged 50 to 65 said they have not filled a prescription, seen a doctor or specialist, or gotten a medical test or follow-up treatment due to the costs involved. more than one-third said they had a problem paying medical bills in the past year, or were still paying off medical debt from the last three years.

All of this is taking a toll on confidence. Only 15 percent of respondents aged 50 to 64 and 22 percent of those aged 65 to 70 felt they would have enough income and savings for retirement. Almost two-thirds worried they would not be able to afford medical care and health insurance in their later years.

Battling an Unfair Health Insurance Claim Can Really Pay Off

Are you having trouble getting your insurance company to pay your medical health costs? Join the club. When managed care entered the insurance scene a decade ago, its mandate was to contain rising medical costs. One way to do that is to deny claims, even when claims are legitimate. The consumer backlash led to many states establishing independent review panels and requiring insurance companies to develop in-house appeal procedures. Forty-two states now have independent review boards whose decisions can override those of insurance companies. Most consumers don’t even realize these review boards exist.

Another problem is that too many people just give up when their insurance claim is denied initially. The appeals process can be long and frustrating and many people don’t have the patience or time to pursue a claim no matter how legitimate. People must be persistent and they can win. Particularly if there’s substantial money involved, the time you dedicate to appealing insurance company decisions can pay off usually more quickly than you think. A Kaiser Family Foundation study recently found that 52% of patients won their first appeal for each claim made. The insurance companies aren’t getting with out paying anymore.

If your first appeal gets turned down, press on. The study found that those who appealed a second time won 44% of the time. Those who appealed a third time won in 45% of cases. Which means the odds are in your favor no matter how long it take. Remember that every time you appeal it costs the insurance company more money to fight you and they are not only going to lose money to you, but also in court costs. Medical health benefits are particularly tricky because insurance companies usually have a cap on the amount of money they’ll spend in a given year, or on the amount of visits they’ll pay for. But there’s often some flexibility when you can document that you or your child’s health warrants more care than your policy usually covers. Here’s how to get started:

Do Your Homework

Read your Policy: What are the benefits? Which kinds of services are included? Outpatient or inpatient care? Is it a serious or “non-serious” diagnosis?

Know the law: Contact your local Health Association to determine your states legal requirements regarding insurance payments for all illness. Does your state require full or partial parity? Are parity benefits available only to patients with “Serious Illness” or is a so-called non-serious illness also included?

Provide written documentation: Some insurance companies may not consider some diagnosis’s serious. In this case, you will need documentation to validate required services. Obtain a letter of medical necessity from your doctor and get test results showing the medical need for you or your child to receive certain services, based on the diagnosis.

Keep good records: Remember, you’ll be dealing with a bureaucracy. Keep the names and numbers of everyone with whom you speak, the dates on which you spoke, and what transpired in the conversation.

Start early: If you can, start the appeals process prior to initiating treatment. If the doctor says your child will need to be seen once a week for a year, begin immediately to appeal your insurance company’s policy of reimbursing only 20 visits a year.

Call and Ask the Insurance Company:

What are the prerequisites for receiving health benefits?

How many visits are allowed annually for you or your child’s diagnosis? Can multiple services be combined on one day and be counted as only one day or one visit?

Which services must be pre-certified–by whom?

Be positive, polite and patient with the customer service representative. Remember that he/she is only the messenger, not the decision-maker. They are the gatekeepers and can either provide you with access to a decision maker or make your life miserable, depending on how you interact with them.

Be persistent. There are no magic bullets. Be like a dog with a bone and don’t give up until you get the answer you want. If you get nowhere after several calls, ask for a supervisor or a nurse in the pre-certification department.

Remember that you do have the right to appeal if your claim is denied. Most consumers get discouraged and will not continue to pursue a claim that should or could be paid. Insurance companies count on that happening, so get out there and claim what’s justifiably belong to you.

Health Insurance It’s Important To Know What’s Not Insured!

Around 7 million people in the UK are covered by health insurance, the majority being covered through their employers. The problem is that few have really studied their policy documents and many misunderstand what is covered. And perhaps just as important, what isn’t. If you expect health insurance to pay all your health costs, you’re mistaken.

Health insurance is designed to provide protection for curable, short-term health problems and allow policyholders to jump the NHS queues to see consultants, be diagnosed, receive surgery or be treated. That sounds fine, but before you buy you need to appreciate the treatments and situations that fall outside the scope of the cover.

But first a word of warning. This article does not relate to any specific policy and the terms and conditions issued by individual insurers do vary. So please ensure you also check your policy documents. After reading this article, you’ll know what to look out for!

Sorry it’s a chronic condition

If a condition can be cured and is not a long-term problem, your insurance company will classify it as acute and should meet the cost. If your problem is incurable or it’s a problem that, despite appropriate treatment, will be with you for a long time, then your insurance company will classify it as chronic – and no, you won’t be covered.

But drawing a firm line between what is acute and what is chronic is fraught with problems, and leads to the biggest area of conflict between insurer and policyholder.

Everyone agrees that diabetes and asthma are chronic conditions as you’re likely to suffer from them for the rest of your life. So those sorts of condition are not covered.

Problems arise when the medical team initially considers a patients’ illness to be curable, but the condition subsequently deteriorates and the doctors change their mind, it’s now become incurable. This can happen especially in the treatment of some types of cancer.

In these circumstances, the condition is initially defined as acute and is therefore insured, but deteriorates and becomes chronic – and outside the terms of cover. This is possible as insurers retain the right to reclassify a condition from acute to chronic during treatment.

Sorry – it’s too long term
The insurance company will not pay out for long term treatment. But you need to check your policy documents to see how they define long-term. You can find the situation where a course of drugs extends for say 12 months, but the insurer will only pay for ten months.

Sorry it’s preventative
Your insurance is designed to pay for the treatment and cure of conditions when they arise. It is not designed to pay for treatments that are used to prevent an illness.

Again, the problem of definition arises. Sometimes it is arguable whether a treatment is preventative or a cure. Take the drug Herceptin for example. This drug can be used in the early stages of breast cancer. Research shows that Herceptin can halve the incidence of cancer returning for women who have a particularly virulent form of the cancer known as HER2. In this situation, is Herceptin offering a cure or is it a preventative?

Insurance companies are split on the debate. Norwich Union, WPA, BUPA and Standard Life Healthcare will pay for Herceptin for HER2 patients whereas Legal and General and Axa PPP will not.

Sorry the drug is not approved
Two of the main attractions for taking out health insurance are: to jump the queues at the NHS, and to get the latest treatments and drugs. But there’s a rider.

Unless the drug has been approved for use by the NHS in England and Wales, by the Institute for Health and Clinical Excellence, your insurer is unlikely to approve its use. The problem is that the Institute’s brief is not simply to decide whether a drug works, but to carry out a cost/benefit analysis to ensure that the benefits to the nation outweigh the financial costs of using it in the NHS. Not an easy brief – and one that has placed the Institute under scrutiny for the extended delays in drug approval.

The compromise hit on by the Financial Ombudsman is that if a health policy won’t pay for the use of experimental treatments, then it should meet the cost of an approved conventional treatment with the policyholder footing the bill for the balance if the experimental treatment is more expensive.

Sorry it’s a pre-existing condition

The basic principle is that if you are already suffering from a condition when you start a policy, then that condition pre-exists the policy and any claims for its treatment are invalid.

For this reason, insurance companies insist you complete an exhaustive questionnaire before they agree to insure you. After all they need a clear picture of your medical condition before they quote. For many applications, the insurer will, with your approval, also write to your GP for specific details of your medical history. They like to have a complete picture.

So lets say some years ago you injured your knee playing football. It appeared to recover but now it turns out that you have a torn cartilage and need an operation. The insurer could argue that this is a pre-existing condition and you have to pay for its’ treatment.

Some insurers try to accommodate these grey areas with a moratorium provision within your policy. These provisions typically say that so long as you have been symptom free for two years relating to any condition you’ve suffered from within the last 5 years, then they will pay for subsequent treatment. Not all policies have these moratorium provisions and the time periods do vary between insurers. You should carefully read your policy.

Sorry its not covered

Health Insurance is an annual contract just like your car insurance. So when it comes to renewal, your insurer is at liberty to review not only your premium but also change the conditions on which your cover is provided.

Therefore, if your policy comes up for renewal mid way through a course of treatment, it’s possible to find that your new policy no longer covers that particular treatment. This means that you will have to foot the bill for the balance of the treatment.

Furthermore, with ongoing advances in medical research, more and more conditions are becoming treatable. This progress has the effect of shifting back the dividing line between chronic and acute conditions.

This hits the insurers’ pocket in two ways. With more conditions being reclassified as acute, the number of claims is increasing. And there’s also a trend for new treatments to cost more Herceptin being a good example. The net result is that the insurers are finding themselves having to pay out far more. This is inevitably passed back to you through increased renewal premiums. And in an attempt to reduce their risk exposure, insurers have a tendency to adjust their definitions and exclusions. This means that you must read your renewal notice closely before you decide to renew.

So when you are considering Health Insurance, be aware that everything is not always black and white. And if you’ve got insurance and need treatment, always contact your insurer without delay and get them to confirm that your treatment is indeed covered

Battling an Unfair Health Insurance Claim Can Really Pay Off

Are you having trouble getting your insurance company to pay your medical health costs? Join the club. When managed care entered the insurance scene a decade ago, its mandate was to contain rising medical costs. One way to do that is to deny claims, even when claims are legitimate. The consumer backlash led to many states establishing independent review panels and requiring insurance companies to develop in-house appeal procedures. Forty-two states now have independent review boards whose decisions can override those of insurance companies. Most consumers don’t even realize these review boards exist.

Another problem is that too many people just give up when their insurance claim is denied initially. The appeals process can be long and frustrating and many people don’t have the patience or time to pursue a claim no matter how legitimate. People must be persistent and they can win. Particularly if there’s substantial money involved, the time you dedicate to appealing insurance company decisions can pay off usually more quickly than you think. A Kaiser Family Foundation study recently found that 52% of patients won their first appeal for each claim made. The insurance companies aren’t getting with out paying anymore.

If your first appeal gets turned down, press on. The study found that those who appealed a second time won 44% of the time. Those who appealed a third time won in 45% of cases. Which means the odds are in your favor no matter how long it take. Remember that every time you appeal it costs the insurance company more money to fight you and they are not only going to lose money to you, but also in court costs. Medical health benefits are particularly tricky because insurance companies usually have a cap on the amount of money they’ll spend in a given year, or on the amount of visits they’ll pay for. But there’s often some flexibility when you can document that you or your child’s health warrants more care than your policy usually covers. Here’s how to get started:

Do Your Homework

Read your Policy: What are the benefits? Which kinds of services are included? Outpatient or inpatient care? Is it a serious or “non-serious” diagnosis?

Know the law: Contact your local Health Association to determine your states legal requirements regarding insurance payments for all illness. Does your state require full or partial parity? Are parity benefits available only to patients with “Serious Illness” or is a so-called non-serious illness also included?

Provide written documentation: Some insurance companies may not consider some diagnosis’s serious. In this case, you will need documentation to validate required services. Obtain a letter of medical necessity from your doctor and get test results showing the medical need for you or your child to receive certain services, based on the diagnosis.

Keep good records: Remember, you’ll be dealing with a bureaucracy. Keep the names and numbers of everyone with whom you speak, the dates on which you spoke, and what transpired in the conversation.

Start early: If you can, start the appeals process prior to initiating treatment. If the doctor says your child will need to be seen once a week for a year, begin immediately to appeal your insurance company’s policy of reimbursing only 20 visits a year.

Call and Ask the Insurance Company:

What are the prerequisites for receiving health benefits?

How many visits are allowed annually for you or your child’s diagnosis? Can multiple services be combined on one day and be counted as only one day or one visit?

Which services must be pre-certified–by whom?

Be positive, polite and patient with the customer service representative. Remember that he/she is only the messenger, not the decision-maker. They are the gatekeepers and can either provide you with access to a decision maker or make your life miserable, depending on how you interact with them.

Be persistent. There are no magic bullets. Be like a dog with a bone and don’t give up until you get the answer you want. If you get nowhere after several calls, ask for a supervisor or a nurse in the pre-certification department.

Remember that you do have the right to appeal if your claim is denied. Most consumers get discouraged and will not continue to pursue a claim that should or could be paid. Insurance companies count on that happening, so get out there and claim what’s justifiably belong to you.

Battling an Unfair Health Insurance Claim Can Really Pay Off

Are you having trouble getting your insurance company to pay your medical health costs? Join the club. When managed care entered the insurance scene a decade ago, its mandate was to contain rising medical costs. One way to do that is to deny claims, even when claims are legitimate. The consumer backlash led to many states establishing independent review panels and requiring insurance companies to develop in-house appeal procedures. Forty-two states now have independent review boards whose decisions can override those of insurance companies. Most consumers don’t even realize these review boards exist.

Another problem is that too many people just give up when their insurance claim is denied initially. The appeals process can be long and frustrating and many people don’t have the patience or time to pursue a claim no matter how legitimate. People must be persistent and they can win. Particularly if there’s substantial money involved, the time you dedicate to appealing insurance company decisions can pay off usually more quickly than you think. A Kaiser Family Foundation study recently found that 52% of patients won their first appeal for each claim made. The insurance companies aren’t getting with out paying anymore.

If your first appeal gets turned down, press on. The study found that those who appealed a second time won 44% of the time. Those who appealed a third time won in 45% of cases. Which means the odds are in your favor no matter how long it take. Remember that every time you appeal it costs the insurance company more money to fight you and they are not only going to lose money to you, but also in court costs. Medical health benefits are particularly tricky because insurance companies usually have a cap on the amount of money they’ll spend in a given year, or on the amount of visits they’ll pay for. But there’s often some flexibility when you can document that you or your child’s health warrants more care than your policy usually covers. Here’s how to get started:

Do Your Homework

Read your Policy: What are the benefits? Which kinds of services are included? Outpatient or inpatient care? Is it a serious or “non-serious” diagnosis?

Know the law: Contact your local Health Association to determine your states legal requirements regarding insurance payments for all illness. Does your state require full or partial parity? Are parity benefits available only to patients with “Serious Illness” or is a so-called non-serious illness also included?

Provide written documentation: Some insurance companies may not consider some diagnosis’s serious. In this case, you will need documentation to validate required services. Obtain a letter of medical necessity from your doctor and get test results showing the medical need for you or your child to receive certain services, based on the diagnosis.

Keep good records: Remember, you’ll be dealing with a bureaucracy. Keep the names and numbers of everyone with whom you speak, the dates on which you spoke, and what transpired in the conversation.

Start early: If you can, start the appeals process prior to initiating treatment. If the doctor says your child will need to be seen once a week for a year, begin immediately to appeal your insurance company’s policy of reimbursing only 20 visits a year.

Call and Ask the Insurance Company:

What are the prerequisites for receiving health benefits?

How many visits are allowed annually for you or your child’s diagnosis? Can multiple services be combined on one day and be counted as only one day or one visit?

Which services must be pre-certified–by whom?

Be positive, polite and patient with the customer service representative. Remember that he/she is only the messenger, not the decision-maker. They are the gatekeepers and can either provide you with access to a decision maker or make your life miserable, depending on how you interact with them.

Be persistent. There are no magic bullets. Be like a dog with a bone and don’t give up until you get the answer you want. If you get nowhere after several calls, ask for a supervisor or a nurse in the pre-certification department.

Remember that you do have the right to appeal if your claim is denied. Most consumers get discouraged and will not continue to pursue a claim that should or could be paid. Insurance companies count on that happening, so get out there and claim what’s justifiably belong to you.