What if insurance denies a claim?

82. What if insurance denies a claim?

If you think that the insurance company has denied a
claim that should have been covered or is discontinuing
coverage, first contact the patient’s insurance company
and/or human resources department if health
insurance is provided via her workplace. Sometimes
simple changes need to be made to fix the problem.

For example, claims can be rejected for reasons such as
having your incorrect birth date or social security
number (SSN) in the computer system or on a form.

If an initial telephone inquiry does not work, write a
letter to the insurance carrier, clearly stating the
claim number, the date of service, the correct personal
information of the patient (policy and group numbers,
SSN, birth date, name, and address), and the reason you
believe the claim should have been approved. Be direct
but pleasant in your tone, and keep a copy of the letter.

The carrier may request additional medical information
before covering certain tests or treatments, and sometimes
sending additional documentation or having the
doctor contact the carrier can resolve these issues. If you
have exhausted all other options, you can contact your
state’s insurance commissioner or hire a lawyer who specializes
in insurance disputes.

Recent legislation at the state and national level exists
to protect patients, in some limited ways, from insurance
coverage lapses due to medical diagnosis and
unfair claim rejections. Private insurance companies
and health maintenance organizations (HMOs) are
most likely regulated by your State Department of
Insurance or State Department of Health. See the
Appendix for specific references to learn more about
these laws and how to seek assistance, including the
National Coalition for Cancer Survivorship’s publication
entitled, What Cancer Survivors Need to Know
About Health Insurance.


Health maintenance organizations (HMOs) = 
An organization providing health care to enrolled members
through a network of member doctors and other healthcare
providers. Designed to reduce costs, HMOs also typically 
restrict access to providers or specialists outside their 
approved networks.


An organization that provides assistance with insurance
matters and can serve as a liaison between patients and
their insurer is the Patient Advocate Foundation. They
have case managers, doctors, and lawyers on staff to
help people resolve insurance issues (as well as job
retention and/or debt matters related to their cancer
diagnosis), with the goal of assuring patients’ access to
care.