How to handle a health insurance claim dispute

Health insurance is a very tricky business. Policies are often dozens of pages long spelling out exactly what is and what isn't covered in a version of English that can be described as nothing but legalese. When medical insurance claims get denied, most people just give up because it's such a mess to deal with the system, but there are proactive steps that you can take to ease the burden on you, make sure everything was done properly, and possibly get the claim paid.

The first thing you need to do is just don't give up. Insurance companies know that a large percentage of people will just give up rather than dealing with the insurance company. Be persistent and diligent in your actions and fight to get your claim paid.

When you do make the first contact with the insurance company, be polite and professional. Yelling and screaming at them for not paying your claim will likely not result in having your claim paid. Be sure to make your contact in writing, telephone calls mean almost nothing in the insurance world. If it's not documented on paper, it's almost like it never happened. The insurance company can simply deny that the call occurred and there's really not much you can do about it.

When you write your first letter, request a copy of the policy. You can't make smart decisions if you don't know what rights and responsibilities you have as laid out by your insurance policy. Read them and find out whether or not you have a valid reason to appeal the rejected claim. In that letter, also ask for details as to why your claim was rejected. Ask them for the provision under the policy that you were excluded by, a specific reason why the claim was denied, the name and license number of the person who decided to deny your claim, a list of any alternative treatment that the policy does cover, instructions for initiating an appeal, and instructions for filing an external appeal if the internal appeal was rejected.

Be diligent, most health insurance companies only allow you to appeal the decision within a short amount of time, often as low as 60 days. So make sure that you start following up immediately after the claim was denied.

If the claim is for more than a few hundred dollars, it's definitely worth visiting an attorney that specializes in health care or insurance. Have them review your claim and determine whether or not there's merit to your case or if there's anything else that you can do. Sometimes an experienced attorney can help solve your problem with a couple of letters. It's not always the case, but it's well worth it to have an expert on your side fighting for you.

Dealing with insurance companies is certainly not the most fun thing to do in the world, that's granted, but don't give up. Be professional, firm and diligent in your actions and make sure that if your claim is ultimately rejected that it is done so for a valid and legitimate reason.

Learn more about this author, Matthew Paulson.