TIPS FOR DEALING WITH INSURANCE COMPANIES

Written by John S. Wesson, Attorney at Law

Father to Ian Wesson - Saggital Synostosis 3/2000

I. Insurance companies answer to a higher authority

In every state there is an agency in charge of monitoring insurance companies to make certain that the insurance companies follow proper procedures and the law.  In the state of Tennessee, this agency is called the Commissioner of the Insurance, (the agency may have another name in your state).  If you feel that your insurance company is being unreasonable, contact this agency.  you should also feel free to inform the insurance company that you are able and wiling to contact this agency.  Insurance companies do not like to be reported to the commissioner (or whatever the agency is called in your state.)

II. Acting in bad faith

You could remember the phrase, "acting in bad faith." which is legal jargon meaning the insurance company is being a money hungry jerk and not paying a claim they know they should pay.  Use this phrase in any heated discussions you may have with the insurance company or in any discussions with the insurance commissioner's office.

III. An insurance policy is nothing more than a contract

An insurance company can be sued like anybody else. An insurance policy is nothing more than a contract. That is, the insurance company is being paid a premium, and in return they pay for your covered medical expenses. When an insurance company refuses to pay for a covered medical cost they have breached the contract and can be sued and forced to pay the bill. An insurance company can be sued even after the medical treatment has taken place (please be aware that you have a limited time after the fact in which to file a lawsuit, so seek the advice of an attorney in your state to find out how long you have). So if time is of the essence, as it certainly is with children with cranial synostosis, and you have not been able to persuade the insurance company to pay, don't wait around for them to approve the claim. Just because the insurance company refuses to pay for the procedure initially does not mean they are off the hook. I am not saying that you will prevail every time you sue an insurance company, I am just saying that you have a right to ask a judge (or jury) to decide. Also it is certainly in your best interest to hire an attorney to represent you in any lawsuit against an insurance company. However, you certainly don't need a lawyers help to threaten to file a lawsuit.

IV. Insurance companies do not want to be sued

Many people believe that insurance companies hold all the cards when it comes to a lawsuit. It is true that they do get sued a lot, however, most insurance companies do not have their own attorneys on staff. They hire them like everyone else, and attorneys do not work cheap. It may cost an insurance company thousands of dollars in attorney's fees to defend a lawsuit against them. Remember this in your discussions with them and use it as leverage to persuade them to pay your claim.

V. "Covered" versus "not covered" is open to interpretation

The big fight with the insurance company is always over the same issue. Is the claim "covered" or not? The insurance policy describes in great detail what is to be "covered" and what may not be. However, no policy can anticipate every possible situation and the wording and meaning of the policy is always open to interpretation. For example, insurance companies often inform people that a claim is not covered because it is an "experimental procedure." If an insurance company tells you that a procedure is "an experimental procedure," you should respond by telling them that their interpretation of the procedure is incorrect. You should tell them that the procedure is a proven effective and medically necessary procedure and send them the information from your physician to back this up. Most physicians have form letters describing the procedures they perform.

VI. Keeping up with the paper trail

Insurance companies need information to pay claims. You are very familiar with your child's medical condition and need for treatment as well as the types of procedures available, but the insurance company may not be. Provide them with the information they need to make a decision about your claim. It is a good idea to send your correspondence by certified mail and ask for a return receipt. Always keep copies of what you send. Remember that insurance companies use lack of information as an excuse not to pay claims. Insurance companies are the world's best at playing "pass the buck." You will likely be given the run around and told to talk to this person or that person. You may be told that you sent the information to the wrong person, etc. Be persistent. Be nice but just a little bit annoying. Insurance carriers have difficult and stressful jobs. Often they will approve a claim just to make you leave them alone. Also keep in mind that the people you speak with are just that ... people. Be assertive with them and be persistent, but always be cordial.

VI. Help is available

Lastly, if you do find yourself left with a mountain of medical debt, the federal bankruptcy court may be able to help you. Bankruptcy laws are designed to help honest but unfortunate people get back on their feet. Often bankruptcy debtors are able to keep their homes and cars while at the same time being forgiven permanently for their other debts.

 

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The information on this website should not be used for medical advice.  Medical or health advice should be provided only by medical or health professionals.

©Craniosynostosis And Positional Plagiocephaly Support, Inc.2001