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Let the
State Help Dispute a Health
Insurance Claim
In
2004, an Ithaca, NY woman filed
a claim with her health
insurance company for a $154
infertility treatment. The
insurance company denied her
claim, as they did for almost
2,500 other claims for the same
treatment.
But the woman from Ithaca was
quite sure the insurance company
was wrong to deny her claim. She
disputed their findings, but
they continued to refuse. So she
filed a complaint with the New
York State Insurance Department.
Turns out she was right. Last
month, the New York State
Insurance Department fined the
insurer, and ordered it to
reimburse those 2,500 women who
had been denied payment.
Why is that important to us?
I often hear complaints from
patients who don’t understand
why a health insurance claim was
denied. They tell me how
frustrated they are trying to
work with their insurance
company. They phone their
insurer’s customer service
department, and are given
answers they don’t understand,
or answers that are incomplete.
Sometimes they call more than
once and get different answers
each time. Too often, because
they are sick and don’t feel
strong enough, patients give up
the fight.
That’s where the state Insurance
Department comes in, to act as a
watchdog for us, its
taxpayer-patient-customers.
If you feel you have been
unfairly refused payment for a
health insurance claim, then
take these steps:
Read your policy carefully,
including the inclusions and
exclusions, to be sure your
claim should be covered. Exhaust
all possibilities with your
insurer. If you continue to be
denied, then file a complaint
with your state's Insurance
Department.
You can find links to all state
insurance departments and file
your complaint online at
http://www.naic.org/cis/fileComplaintMap.do
When you file a complaint, no
promises are made about whether
there will be an investigation,
how long one might take, or that
you will prevail in the dispute.
But if you are fed up, are sure
you are right, and need a place
to go where steps may be taken
to prove your case, then know
your tax dollars have paid for
this valuable service that will
help you arrive at the right
answer.
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Trisha Torrey is Every Patient’s
AdvocateTM.
She offers no medical advice,
but empowers those who
want to learn more about
diagnosis and treatment options
by
providing useful tools and
resources.
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