FAQ: Health Insurance Claims
Get Answers from Chris Dilworth
Still have questions about your potential claim and the law surrounding health insurance? Provided here are some of the typical questions which clients have asked me. If you don't find what you're looking for, please contact me directly.
Insurance company refuses to pay?
Can we sue the company?
What is the appeals process?
Met the deductible, but continue to get
billed?
Bills applied to the wrong type of
deductible or not credited at all?
How much do you charge?
Q: What can you do to help if I, or someone in my family, needs medical treatment and the insurance company refuses to pay?
A: After I have reviewed your insurance policy, along with any amendments and riders, I can tell you whether your treatment is covered. If it is covered and appears to be medically necessary, I can explain your legal options. (TOP)
Q: If you feel that we have a valid claim, can we sue the company for the cost of treatment?
A: Yes, but first you will probably have to go through an appeal process. (TOP)
Q: What is the appeal process and how long does it take?
A: In most cases, especially in managed care plans, when the insurance company denies your claim for benefits you have to go through an administrative process before you can file suit. This is called either the grievance or appeal process.
The first step is to file a Level One Appeal, which means notifying your insurer that you want to appeal their decision to deny payment. To be safe, you should notify the company in writing. (Always make copies of your letters and other insurance related records, and keep them in a safe place.) Once you've done this, the insurance carrier gives your medical records to one of its full time employees, called a "medical director" or "physician advisor." This insurance company doctor reviews the case and either upholds the denial or reverses it. If he upholds the denial, you can request a Level Two appeal. Unlike the Level One procedure, you are entitled to participate in a Level Two hearing, and you can present any relevant documents and records to the "hearing panel." In addition, you are entitled to present testimony from witnesses and to have an attorney represent you. You have to pay for the attorney out of your own pocket.
The "hearing panel" for a Level Two appeal is supposed to include at least two medical doctors who specialize in the type of treatment that you or your relative is undergoing. In addition, the Level One doctor cannot be on the Level Two panel, although he is allowed to testify.
The Level Two hearing is held in a conference room at the insurance company and people can participate by speaker phone. The hearing is recorded by the company. The Level Two hearing is usually limited to one hour. The insurance company has to notify you of its decision within five working days of the hearing.
If you lose the Level Two Appeal you can request an "external review." This is the last stage of the administrative appeal process. The "external review" is done by an independent medical reviewer who is hired by the Maine Bureau of Insurance, and paid for by your insurance company. The "external review" is almost identical to the Level Two appeal, except that the doctor in the external review does not work for the insurance company.
If you win the external review, the insurance company has to pay the cost of treatment within 30 days. If you lose, you can then sue the insurance company in state or federal court, but the insurance company is allowed to use the external review decision in its own defense. (TOP)
Q: I think I have met my deductible and/or coinsurance limit for the year, but my insurance company keeps billing me the full cost of treatment. Can you help me sort this out?
A: Yes. I will need to see your policy, riders, amendments and summary of benefits, along with the EOB's (explanation of benefits) that your company sends in response to every medical bill it receives. If you haven't kept these records, you can ask your company to send you a complete set. (TOP)
Q: I have different deductible and coinsurance limits for different types of care. My hospital deductible is much higher than my rider deductibles. Some of my bills seem to be applied to the wrong deductible, and others aren't counted towards any deductible. Can you help me sort this out?
A: Yes, provided you can get me the records I mentioned in the previous answer. (TOP)
Q: How much do you charge?
A: I won't charge anything to review your policy and your medical/billing records. I wil also meet with you to answer your questions and to give you my opinion about the case. Again, this is free.
If I think that the case is worth pursuing, and if it falls under one of the statutes that provides for payment of attorney's fees, then I will represent you for free. If we win, I will ask the court to order your insurance company to pay my fees. If we lose, I get nothing. (TOP)