An insurance claims dispute refers to any time you, or someone covered under your insurance policy, is denied a claim. This can be for medical care already received or medical care recommended by a physician. Before losing your cool and letting your emotions take control, try the following steps.
(1) First of all take a deep breath and count to 10 before speaking to anyone on the phone or in person. Getting angry or upset will not help your case.
(2) Now that you’ve calmed down some, find all your paperwork from the insurance company. You will need any bills sent by the doctor or hospital, all of your documents stating what is and is not covered, and any letters from the insurance company that denies the claim.
(3) Go through your policy with a fine tooth comb, and make notes of everything you find. Pay special attention to anything that relates to the current condition.
(4) Now its time to call the insurance company. Make sure to keep track of the times you called, and if you can find a witness to verify the call, get one. Using a calm tone, explain the situation and tell the claims adjuster that you think it was an error. Get a specific date on when the claim will be resolved, and call back if it doesn’t happen. Before making the call, take notes on your policy and explain your findings to the representative. Many people call without understanding the process, and those people usually leave without finding any help or resolving the situation.
(5) If the claim is not resolved, and the insurance company refuses to cooperate, contact the Department of Insurance for your state. Consult them on what you need to do, to file an appeal.
(6) Now its time to make another phone call to the insurance company. Explain why you believe the claim should be covered, and offer documenting proof. Make sure to keep careful notes of everyone you talk to over the phone. Remind the representative that the claim was supposed to have been resolved by a specific date, and refer them to the date of your original phone call and the date you were quoted.
(7) If the claim is paid, keep checking your statement to ensure that the proper amount was paid, and that you do not owe more than you should.
(8) If your claim is still denied, don’t hesitate to get your doctor involved. He may be able to clarify the situation with the insurance company.
(9) If your claim was denied, but was previously covered, explain this to the insurance company and ask for written clarification as to the change.
(10) Consider researching similar claims in the area. Ask local doctors their fees for the same service, and use that when speaking to the insurance company.
(11) If the policy is part of an employer program, talk to the head of the program. They may be able to help settle the claim.
(12) There are some cases where you cannot get through to someone over the phone. In those situations, write a letter to the insurance company, but keep copies of all correspondence in your records. If you do not get a response, be persistent; keep writing until you do get one.
The number one thing to remember, is be in control of the situation. Don’t raise your voice or yell at the representative because that will make them less likely to help you.
Good luck!