Why health insurance claims get denied/rejected and how to appeal against them? (Part 2/2)

In part 1 of this blog series, we have already outlined various reasons for health insurance companies rejecting the claims made by their clients (Click Here to go to part 1). In part 2, Student Cover focuses on providing the readers with remedies that are available to address the issue of claim rejection.

If a health insurance provider somehow either rejects the claim or denies all benefits, it is not the end of the road for the client. He has the right to appeal against the insurance company’s decision. If an appeal is properly made and if it is later found that the insurance company erred in either rejecting or denying insurance claim, they reverse their earlier decision and provide reimbursement for the treatment expenditure incurred to the client.

Before one appeals against rejection or denial, one must do the following:

1. CHECK THE REASON STATED FOR REJECTION OR DENIAL – Health insurance companies can’t deny benefits to clients just because they want to. It has to be based on certain and sound logic. Every health insurance company, while denying or rejecting the claim provides reason for such action. A client has the right to seek in writing the reason stated by the insurance company for its decision. Then, he or she must go through the stated reason and find out if it is justified or not. Claim could be denied or rejected due to incomplete documentation, treatment not covered by the policy or some other reason.

Note: Buyers of health plan are advised to contact their insurance provider to get detailed information about the reasons for denial/rejection of claims. Those who have purchased health insurance through Student Cover or its site www.intlstudentcover.com may contact us directly for any claim related queries. Student Cover assists students in claims and claims and all related processes free of cost.

2. GO THROUGH THE POLICY DOCUMENT – After getting the reason for denial or rejection, the next thing to do is to go through the policy document. A policy document clearly states the terms and conditions laid down by the insurance company. It has information pertaining to the claim process, the important deadlines, exclusions, conditions for denial etc. One must read each and every paragraph carefully to understand the reason behind denial or rejection of the claim.

3. IDENTIFY THE CONTRADICTIONS IF ANY – The appeal has a high probability of acceptance if the denial or rejection is in direct contradiction of the provision of the rules, terms and conditions laid down by the health insurance company. For example, if a rule states that the health insurance company will cover for a particular disease but the rejection or denial letter states the opposite, he or she can appeal against it.

THE APPEAL PROCESS

Each health insurance company provides detailed instructions with regard to filing an appeal against its decision. One should either check their website or call the customer care number to get the instructions including the deadline for filing an appeal.

1. CALL THE HEALTH INSURANCE COMPANY – Almost all health insurance companies have dedicated departments and executives to deal with insurance claim and related grievances. The first step towards an appeal is to call the customer care number and ask the executive about the detailed process involved in formally registering an appeal.

2. GATHER ALL RECORDS AND DOCUMENTS – In case the claim was denied or rejected due to insufficient documentation or error, it is essential to gather the documents that were not submitted last time. One is also advised to call up the hospital and seek any document that was essential for claim but was not provided by the hospital. If there was coding error on part of the physician or hospital, it should be rectified.

3. SEND A DETAILED APPEAL LETTER WITH SUPPORTING DOCUMENTS – Whether to send an email or a snail mail depends on what the health insurance provider instructs the customer to do. However, the appeal letter should be straight forward and highlight the reasons why the claim should be accepted. One should provide supporting documents in order to strengthen the case. In the appeal letter an insured can also demand a review of the claim. One can demand either internal or external review.

a. Internal Review – In this review, the health insurance company goes through the claim and the appeal made by the insured person and conducts and free and fair review of its decision to reject or deny the claim.

b. External Review – In this review, an independent third party gets to review the health insurance company’s decision and reach a conclusion whether it was fair or unfair on part of the company to reject or deny the claim. The health insurance company, in this case, no longer has the right to decide on the outcome of the review and hence, on whether to accept or reject/deny of the claim.

4. FOLLOW UP – One the appeal is filed, it usually takes some time for the health insurance company to provide information on the final outcome of the appeal. One should regularly follow-up with the health insurance provider and find out the latest development in the case.

LET’S WRAP UP!

Rejection or denial of health insurance is not the end of the road for the insured. He or she has the right to appeal against the company’s decision. In order to ensure that the appeal leads to positive result, one should go through the reason provided by the company for rejection or denial, compare it with rules, regulations, terms and conditions of the policy document and find if the company has erred in taking decision. One should then call the health insurance company, file a formal appeal and follow-up on it.

Disclaimer: The content of the blog is based on personal research of the write. Readers’ discretion is advised. Neither Student Cover nor the write will be held responsible for any wrongful interpretation of the content of this blog.