Insurance World

Are you having trouble getting your insurance company to pay your medical health costs? Join the club. When managed care entered the insurance scene a decade ago, its mandate was to contain rising medical costs. One way to do that is to deny claims, even when claims are legitimate. The consumer backlash led to many states establishing independent review panels and requiring insurance companies to develop in-house appeal procedures. Forty-two states now have independent review boards whose decisions can override those of insurance companies. Most consumers don’t even realize these review boards exist.

Another problem is that too many people just give up when their insurance claim is denied initially. The appeals process can be long and frustrating and many people don’t have the patience or time to pursue a claim no matter how legitimate. People must be persistent and they can win. Particularly if there’s substantial money involved, the time you dedicate to appealing insurance company decisions can pay off usually more quickly than you think. A Kaiser Family Foundation study recently found that 52% of patients won their first appeal for each claim made. The insurance companies aren’t getting with out paying anymore.

If your first appeal gets turned down, press on. The study found that those who appealed a second time won 44% of the time. Those who appealed a third time won in 45% of cases. Which means the odds are in your favor no matter how long it take. Remember that every time you appeal it costs the insurance company more money to fight you and they are not only going to lose money to you, but also in court costs. Medical health benefits are particularly tricky because insurance companies usually have a cap on the amount of money they’ll spend in a given year, or on the amount of visits they’ll pay for. But there’s often some flexibility when you can document that you or your child’s health warrants more care than your policy usually covers. Here’s how to get started:

Do Your Homework

Read your Policy: What are the benefits? Which kinds of services are included? Outpatient or inpatient care? Is it a serious or “non-serious” diagnosis?

Know the law: Contact your local Health Association to determine your states legal requirements regarding insurance payments for all illness. Does your state require full or partial parity? Are parity benefits available only to patients with “Serious Illness” or is a so-called non-serious illness also included?

Provide written documentation: Some insurance companies may not consider some diagnosis’s serious. In this case, you will need documentation to validate required services. Obtain a letter of medical necessity from your doctor and get test results showing the medical need for you or your child to receive certain services, based on the diagnosis.

Keep good records: Remember, you’ll be dealing with a bureaucracy. Keep the names and numbers of everyone with whom you speak, the dates on which you spoke, and what transpired in the conversation.

Start early: If you can, start the appeals process prior to initiating treatment. If the doctor says your child will need to be seen once a week for a year, begin immediately to appeal your insurance company’s policy of reimbursing only 20 visits a year.

Call and Ask the Insurance Company:

What are the prerequisites for receiving health benefits?

How many visits are allowed annually for you or your child’s diagnosis? Can multiple services be combined on one day and be counted as only one day or one visit?

Which services must be pre-certified–by whom?

Be positive, polite and patient with the customer service representative. Remember that he/she is only the messenger, not the decision-maker. They are the gatekeepers and can either provide you with access to a decision maker or make your life miserable, depending on how you interact with them.

Be persistent. There are no magic bullets. Be like a dog with a bone and don’t give up until you get the answer you want. If you get nowhere after several calls, ask for a supervisor or a nurse in the pre-certification department.

Remember that you do have the right to appeal if your claim is denied. Most consumers get discouraged and will not continue to pursue a claim that should or could be paid. Insurance companies count on that happening, so get out there and claim what’s justifiably belong to you.

There are basically two main kinds of life insurance policies – term life insurance, and whole life insurance. Of course, there are subcategories of each kind, but, in general, term life insurance and whole life insurance are the two main categories of life insurance.

Most of us are familiar with term life insurance, as it tends to be the more popularly chosen of the two. It is less expensive, and it only lasts for as long as you need it to. However, not many of us are familiar with whole life insurance. We need a whole life insurance explanation. What exactly is a whole life insurance policy?

Whole life insurance is life insurance that covers you for the entirety of your life, as opposed to term life insurance which only covers you for a certain number of years. With a whole life insurance policy, your beneficiary will receive a death benefit. Sounds pretty standard, right? Well, whole life insurance policies also offer you the option of fixed premiums, which means you will pay the same amount for you whole life insurance policy for the entire time you have it, as long as you faithfully keep up with payments. Your premiums will not increase! You can withdraw money from your policy at anytime without paying it back, and you can even choose to receive dividends that can be paid toward reducing your payments.

Yet, even with all of those great benefits, there are some drawbacks to having a whole life insurance policy. For example, the “investment component” that comes along with a whole life insurance policy is not always what it is cracked up to be. Whole life insurance policies are no account flexibility. This means you can not spread your money among different accounts, nor can you move your money from one account to another. Whole life insurance policies also will not allow you to invest your money into different accounts.