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Persistence, Show of Respect Can Pay Off in Claims Chase

June 01, 1993|SHARI ROAN

It's not easy to take on any bureaucracy. So don't waste all your energy being angry, says Marian Miller of Victims of Insurance Company Errors: "There is no one phone number people can call. There is no magic solution. So many people lose their cool and let their anger and frustration dominate them. Channel that anger into determination."

Many consumers get too mad for their own good, says Mary Thompson, an insurance consultant: "You have to be persistent and firm, but always try to treat the claims person with respect. Because they hold the key to whether or not you are going to get paid."

Here are other tips for pursuing a reimbursement:

* Try to get past the claims representative. Ask to speak to the supervisor because your claim "is complicated."

* Get the first and last names of anyone you speak to.

* Take notes on everything that is said. Note the date and time of each call.

* Keep copies of everything.

* Send all letters and medical records by certified mail. Ask your doctor to send records by certified mail.

* If your claim is still denied, file an appeal. Begin your appeal letter by stating the claim and policy numbers. Stick to the medical facts. Be clear and concise. Try to refer to the part of the policy in question.

For example, Thompson says, if your claim was denied because it was not "medically necessary," read the part of your policy regarding that definition and try to show why your case meets the definition.

"State in the letter that if they still feel it should be denied then you need to have specific reasons why it is denied, relating to your situation," Thompson says. "Ask under what policy definition it is being denied."

Responding to this request, she says, may be more trouble to the insurer than simply paying the claim.

* Remind the insurer that "I know you want to do your fiduciary duty." Not doing their "fiduciary duty" can involve big penalties, says Fred Hunt of the Society of Professional Benefit Administrators.

* If your appeal is denied, try to call on the top executives of the company and complain.

"In your second appeal you should say you have no intention of dropping this and that you will be getting in touch with your attorney," Thompson says.

* Seek the advice of an attorney specializing in insurance bad faith. Some attorneys, for a small fee, will write a letter on law-firm letterhead requesting the claim be re-evaluated within 30 days, Thompson says.

"Many times, a company will handle an attorney's letter differently," she says. "In 90% of cases, they will not go to court."

* Maintain a good relationship, if possible, with your doctor.

"A lot of times insurers will say they are waiting for more information from the doctor," Miller notes.

* Know your policy. Many companies give their employees only a small booklet with general information about the policy, not details that might pertain to your situation. If you are not sure whether you have been wrongfully denied payment, ask your employer for a copy of the master policy and read it. There may be a small fee for the copy. But there is a federal penalty if the employer does not comply.

* Try to enlist your company health benefits office to lobby on your behalf.

* If you are a union member, involve the union in your complaint.

* Question the medical director of the insurance company or its utilization review committee to see if they are up to date on the latest medical treatments. Many individuals who have been in these positions for many years fall behind on the latest advances, Thompson says.

* Know your medical records. Some people are dropped or denied coverage because of their medical history. Check for errors or misinterpretations in your history.

* Send copies of your complaint letters and appeals to your political representatives.

* File a complaint with the California Department of Insurance and the federal Department of Labor. If you belong to an HMO, file your complaint with the Department of Corporations.

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