Phillips: Persist in getting insurance to pay

Phillips: Persist in getting insurance to pay

January 16th, 2010 by Ellen Phillips in Business Ellen Phillips

Q: Even though I've got health care coverage through my company, I'm having a hard time getting a hospital claim paid. After an emergency room visit following a bad fall and paying the $300 deductable upfront, I never dreamed my insurance company would refuse to pay its part. I've called customer service a couple of times, but my claim is still denied. I can't afford to pay almost $5,000 out-of-pocket. - Agitated Agatha

A: Dear Agatha: According to patient advocacy groups, insurance companies have become more and more hard line about paying claims, especially for expensive treatments such as cancer and Parkinson's disease. Because so many of us bleat like sheep led to the slaughter (my clever way of saying too many of us are weenies!), these companies continue to get away with theft of our hard-earned money and the amounts we pay in premiums.

In fact, the U.S. Department of Labor tells us about one in seven claims is initially denied with reasons ranging from a simple clerical error to someone's decision that whatever treatment we received wasn't medically necessary. ("Oh, wait, Doc. Don't sew my upper lip back on. My insurance company doesn't think I really need two lips!")

So what to do? I'll devote this week's column and the next to painless remedies that get the job done without having a mental breakdown. (The company probably won't pay for that, either.)

Appeal, appeal, appeal. Never accept as final what the company tells you. Frankly, most of them depend upon what they call the "hassle factor." In other words, the baddies think (and rightly so, unfortunately) we are too frustrated, too busy, and/or don't think appeals work so we sit back and let them steamroll over us.

Instead, we must make these folks sit up and take notice that we're not going away until one of us is dead as a door knob so they'd better deal with us responsibly. Fighting a denial is really quite easy, as long as you take the time for a few initial steps.

Obviously, the first item on your agenda is simply do not pay the bill. Don't stop there, though; follow up your denial by asking the specific reason - in writing - the insurance company refuses to pay.

Be sure to carefully check your policy so as to follow the instructions to file an appeal. In preparation for an operation this month, I contacted the surgeon to obtain the insurance codes. When I called the company, naturally the representative spouted "usual and customary" fees (or "not," in my case). At that point, I had to investigate fees for surgeons in surrounding areas before my company decided I couldn't get the same surgical fix by going elsewhere and so agreed to increase my benefit.

Two lips surgery? Be prepared to back up your claim that treatment is a medical necessity. It definitely pays to do your homework.

To be continued.

Ellen Phillips is a retired English teacher who has written two consumer-oriented books. Her Consumer Watch column appears on Saturdays in the Business section of the paper. An expanded version is at under Local Business. E-mail her at consumerwatch@timesfree