Medical insurance

Practical tips for disputing a medical claim denial by an insurance company

  1. To dispute a medical claim denial, you first have to understand why the medical claim was denied. Be sure to carefully review your medical bills, medical notes and medical reports, and the terms of your medical insurance policy. Your policy explains what your insurance company covers and excludes.
  2. If you see fit, you may approach the insurer concerned to lodge a complaint. You may speak to a representative about your dispute and ask for the reasons for denial. This would give the insurer concerned a chance to look into the matter with a view to resolving your complaint at an early stage.
  3. If there are any errors on your medical bills, contact your doctor for clarification and correction. If your claim is denied for another reason, ask for an explanation and the specific steps needed to appeal your claim denial.
  4. Call your doctor's office. If your claim was denied because of an error in your information, ask the office to resubmit your claim with the correct information.
  5. Talk to your doctor. Ask your doctor about the medical necessity of your medical procedure. If your doctor feels that the procedure was necessary, he or she is likely to write a letter to your insurance company explaining why the procedure was necessary.
  6. Obtain a letter of medical necessity from your doctor. The letter of medical necessity should say why it was necessary for you to receive the denied procedure and why no other procedure would have been adequate.  Send a copy of this letter to your medical insurance insurer to support your appeal.
  7. Write a letter to your insurer disputing the claim denial. Include your name, personal particulars, reason given for the denial, reason why you or your doctor feel that the claim should be covered, and what you would like the insurance company to do. You may ask the insurance company to reconsider its decision and cover your claim. Include any supporting documents, including a letter from your doctor and/or your medical records.
  8. Act in a timely manner. Respond immediately to all correspondence from the insurance company. Many insurance companies have a time frame in which they allow you to dispute medical service denials. Pay attention to the prescribed time limitation.
  9. If you feel aggrieved by your insurer’s denial of claim or inadequate payment for your claim, your policy usually provides a procedure for arbitration as a method for settling disputes.
  10. You can also file a complaint with the independent 'Insurance Claims Complaints Panel' (established by The Insurance Claims Complaints Bureau). The Panel's decision is binding only on the insurer, not the policyholder.
  11. If you still feel aggrieved after the Panel's decision, you can resort to arbitration or litigation.
  12. Consult your lawyer if you are in doubt about any of the above.