Checklist for Negotiating With an Insurer for Medical Coverage

If you have a chronic medical illness, the last thing you want to hear is that your insurance company is denying coverage. If you are denied coverage of medical care, home health care, medical equipment, or medical supplies, you may have to negotiate with your insurance company for coverage. The following are a few tips to help you secure coverage for yourself.

• Request an explanation from your insurance company. The first step is to request from your insurance company a detailed explanation of its denial, based on the terms of your policy or plan. You are entitled to an explanation for the denial and the terms of the insurer’s policy that support that denial. Ask the company representative to point to the specific clause in your insurance policy that supports the insurer’s denial and to put this information in writing. If the insurer relied upon internal scientific or procedural guidelines to deny your claim, you are entitled to copies of these as well. Many companies maintain guidelines on their Internet sites. Regardless, you should request, in writing, any internal guidelines, scientific, medical or otherwise that influenced the insurer’s decision to deny your claim.

• Request and read your policy. You should next request from both your employer and your insurance company a copy of your policy (or plan). Your policy is not the five-page summary plan description provided by your employer every year, nor is it the brief summary of benefits provided by your insurance company. Your policy is a detailed booklet that specifically enumerates what is covered, exclusions to coverage and relevant definitions, such as that for medical necessity. You are entitled to a copy of your plan document, and should make your request in writing. Read your policy (or plan) thoroughly, and find all the relevant terms, not just the one cited by the insurance company to deny your claim. Determine whether or not the denial is justified both medically and under the plan. If you are in doubt, show the policy terms to your physician. Remember, your plan is a contract between you and your insurance company, and the terms alone govern your relationship.

• Request a copy of your claims file. You are entitled to a copy of your claims file from your insurance company. The file contains valuable information that can be used to prove that the insurance company’s reasons for denying your claim are wrong, including the insurer’s own medical reviews. Use this information to your advantage. Ask your treating physicians to respond to the specific reasons the medical reviewers gave for denying your claim. Don’t stop there. Question the credentials of the reviewers. Do they have experience with treating and caring for individuals with your illness? Have they spoken to your treating physicians about the care you require? The answers to these questions will provide the basis for challenging the insurance company’s denial.

• Build a record. Write letters to your insurance company questioning the denial, and appeal the denial under the company's internal appeals process. More often than not, coverage is denied on the grounds that it is not "medically necessary." The definition of medically necessary is located in your policy. You must prove to the insurance company that the care you require is not just something you want, but is essential to your health. Establish this point by submitting letters from your doctors, and any other experts you have seen, detailing the medical necessity of the benefits you need. Ask them to explain why they believe the care is medically necessary using the definition in your policy. Keep copies of all correspondence to and from the insurance company and keep records of all telephone calls.

• Be polite. This is essential. In every insurance company, somewhere along the line, there is a knowledgeable employee waiting to help. Don’t burn bridges. If you approach the case from a problem-solving rather than an adversarial perspective, you may gain good general advice and valuable insight into the workings of the overall bureaucracy. By making a valuable ally out of this person, you may ultimately gain a good inside advocate.

• Draw attention to your case. Do not be afraid of "going public" with your claim. Write your senator and/or representative, and ask them to contact the insurance company. Contact the press. You have a real, pressing need for medical care and ought to have access to it. In this current climate where the phrase "managed care" connotes restricted health care access, the shared sense of vulnerability that the general public feels can help you gain valuable support.

• Be tenacious. Make your presence known. Let the insurance company know that you will not go away until you receive the coverage you believe is owed you. Don’t be afraid to ask for help--from your doctor, a local non-profit organization that deals with your condition, or, if necessary, a lawyer.

This article was written by Mala M. Rafik, Esq. and S. Stephen Rosenfeld, Esq. of the law firm of Rosenfeld & Rafik, P.C. in Boston, MA.