Denial of Health Insurance Claims

From the AARP website, http://www.aarp.org/

“Q. If my health insurance company denies my claim, does the health care reform law make it easier to fight that decision?

A. Yes, the law provides you with new rights not only to appeal denials within your plan but, if the plan won't budge, you can get an unbiased decision from an outside review organization. And that decision won't merely be advisory, as it has been in some states. If you win, your insurer will have to pay for the benefit it denied.

The ability to appeal to an independent group of experts is a "key element" of the law, said Karen Pollitz, director of the new Office of Consumer Support in the U. S. Department of Health and Human Services. "When we talk about putting Americans back in control of their health care, this is a prime example of how," she said.

The law also creates consumer advocates in every state who can make sure you don't become hopelessly overwhelmed by incomprehensible rules.  Nearly everyone who has health insurance will be able to challenge an insurer's decision to deny a benefit, whether it is denied outright or reduced or terminated. For example, you can appeal if your insurer decides:

• Your emergency room visit was not medically necessary.
• The treatment you received was experimental.
• The medical test you received isn't covered.
• The treatment you received was related to a preexisting health condition.
• Your coverage was canceled because you provided inaccurate information on your enrollment application.

After July 1, insurers are required to clearly state the reasons for the denial. They must also explain in plain English — and not in the fine print — how to appeal the decision both within and outside the plan, as well as also provide contact information for the consumer assistance office or ombudsman. In areas of the country where a significant portion of the population speaks a language other than English, the denial and appeal information must be provided in that language.

You have 60 days from the time you receive the notice of denial to file an internal appeal with your plan, and four months from the time you receive the denial notice to file an external appeal. You can contact your plan or your state department of insurance for more details."