Health Insurance –What You Don’t Know Can Hurt You A Whole Lot
Films like Michael Moore’s “Sicko” paint a pretty bleak picture of insurance companies denying claims right and left. It is said that when in the midst of fighting an illness, a person may also have to deal with wrestling with their health insurance provider over a denied claim. But the truth is, according to insurance experts, most of the time that people go through this experience, it is because they simply were not as aware as they should be of the limitations of their health insurance policy.
The best defense, the health insurance experts say, against a surprise bill for a medical procedure when you least need it, is to read your policy carefully. Know the limits and exclusions of your health insurance policy before you get sick. Read and understand all of the fine print. If you do not and you are receiving group health insurance from your employer, schedule an appointment with your benefit director, and get whatever you do not understand explained to you. If you have private medical insurance and you are unclear about anything in your policy, speak to your agent or to your healthplan’s customer service department.
This proactive approach to using your health insurance effectively means not only being sure that you understand your policy before you actually need it, but health insurance experts also agree that whenever possible you should get pre-approval for a treatment. With pre-approval from your insurance company, especially for certain treatments that often get flagged as “experimental” such as cancer treatments, it is less likely that those claims can be denied.
However some experts are quick to point out that seeking pre-approval can also trigger a little known tactic by the insurance companies called a recession review. In a recession review an insurance company will go back over your original application very carefully. If they find anything inconsistent, especially as relates to the condition for which you are filing a claim, they can by law rescind your health insurance policy. Again the experts say your best defense is to be careful, to know what you are putting down on your application, and to be 100% honest. If there is any medical question regarding if you have received treatment in the past for a given disease or condition, and you are not sure if you have or have not – put that –”I am not sure.”
Whether seeking pre-approval or appealing a denied claim by your health insurance provider, it is important that you get information in writing from your doctor specifying why he feels the procedure is medically necessary. It is also best that he backs that up with published clinical data in recognized peer reviewed medical journals.
And speaking of documentation, be sure that any and all correspondence with your health insurance company whether your claim has been denied or not, is done in writing or in e-mail. If you must correspond by phone – be sure you get the name and ID number of any representative you speak with and document the time and date of the call.
Keep all of your records regarding a health insurance claim, even one that has been processed for at least 4 years according to the pros.
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