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Shelly Leeke Law Firm, LLC

Top 10 Strategies for Dealing with Health Insurance Denials

Fighting your health insurance for denying your claim can be frustrating and confusing. At first you don't even know why the claim was denied and then you don't know what to do about it. Well here are 10 stragegies that can help you get through this confusing and daunting task.

1) Always be polite and professional. I know it is frustrating, but being rude and abrasive will only lead to more problems. People give what they get.

2) If it's not in writing, it never happened. If your benefits have been denied, get the notice of denial in writing with the reasons for denial from the insurance company. Then write back with all of the reasons why you believe your claim should not have been denied. If you must have a phone conversation with a representative of the insurance company, ask that they confirm the conversation in writing. You should also confirm the conversation in writing by sending a letter to the insurance company. Your letter could read: "I am writing to confirm our conversation of [date and time]. You advised that the specific reason that this claim was denied is for [reason] and no other reason. If this is incorrect, please notify me in writing within the next 10 days. Thank you for your assistance." This letter can also be changed for upcoming procedures as well. For instance: "You advised me that my upcoming surgery is a covered benefit under my policy. I am relying on this conversation and am going forward with the surgery. If this is incorrect, please notify me in writing within the next 10 days. Thank you for your assistance."

3) Get a complete copy of your insurance policy. Make sure you have a complete copy of your insurance policy, including any amendments and summary plan descriptions. Most importantly read these documents.

4) Get the reason for the denial in writing. If any benefits are denied you are usually entitled to a copy of the internal plan guidelines that were used in denying your claim.

5) Read everything they send you. Make sure there are no conflicts between the materials, particularly from your employer. Usually, the "small print" cannot limit the summary description your employer gave you.

6) If they use the "preexisting condition" exclusion, get the medical records they relied on for this conclusion. Ask for a copy of the complete medical records they used to reach their conclusion for denial under the "preexisting condition" exclusion.

7) Get any internal notes, memoranda, and telephone transcripts about you and your claim. They say, "This call will be monitored or recorded," for a reason. Now use it for your benefit.

8) Make sure you know exactly what bill is being denied. Ask for a letter explaining what bill is being denied and the reasons for the denial.

9) Once you have all relevant documents, go back to the healthcare provider. See if your healthcare provider can assist you in reversing the denial.

10) If all else fails, speak with a licensed insurance attorney. Remember attorney's fees and costs can be expensive. It is important that you are certain that the insurance company erred in denying your claim. If you feel certain that the insurance company should not have denied your claim, then contact a licensed insurance attorney in your area for assistance.

Shelly Leeke
South Carolina Injury Lawyer

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