Filing an appeal to collect your health insurance claim – Be Sure To Review the Policy
Whether you are healthcare provider or business seeking collection of an out-of-network claim, or an individual disputing a denial of a healthcare claim, one of the most important things to do at first in analyzing your case is to review the health insurance policy or other plan document.
Know what your Health Insurance Policy is called
For HMOs the policy is called the Evidence of Coverage. For self-insured plans, it is called the Summary Plan Description. For PPOs and indemnity plans it is called the Policy.
What to do if you want to appeal a healthcare claim
These documents, by whatever name, will always contain a description of what to do if you want to appeal. You, or your attorney or other representative, must follow these steps before you can sue. They are called “administrative remedies”. If you do not follow them, and you are forced to sue to collect, the insurance company will ask the court to dismiss your case and the courts will usually do so. This is called “failure to exhaust administrative remedies”.
One defense if you do not exhaust the remedies per the plan documents is to claim that it would have been futile for you to do so because you had already appealed informally and been denied. Or you could claim the insurance company previously stated that under no circumstances would it pay your claim. It is up to the judge whether he or she will buy your argument.
Your Health Insurance Provider must follow the policy
Another very important reason to review the plan document is that the plan must, by law, follow it. The administrators of all health plans are deemed to be “fiduciaries”. That means that they owe you, and your assignees if you assigned your benefits to your healthcare provider, a duty to handle your claim reasonably, in accordance with the plan document, and in your best interests.
Therefore, whoever is denying your claim must have grounds in the plan document on which to support the denial. I have found that they often do not follow the plan document, or ignore plan provisions that are helpful to you.