Challenging a claim

The key to obtaining the maximum benefit from your insurance policy is to keep accurate records and to challenge any denied claims. Some tips on good recordkeeping are:

• Make photocopies of everything you send to your insurance company, including claims, letters, and bills.

• Pay bills by check, and keep all of your canceled checks.

• Keep all correspondence you receive from billing companies and insurance.

• Write down the date, name of person contacted, and conversation of all phone calls concerning insurance.

• Keep accurate records of all medical expenses and claims submitted.

Policyholders have the right to appeal a claim denial by their insurance company.

The following are suggested steps to contest a claim:

• Keep original documents in your files and send photocopies to the insurance company with a letter outlining why the claim should be covered. Make sure to get the reply in writing.

We were making inquiries into hospice care, feeling it was time to explore that option. I found out that the only pediatric hospice provider in the state of Georgia was not on the preferred provider list. They would pay for benefits, but at a reduced rate; not a good thing since the lifetime maximum for hospice care was $7,500. With these benefits, we would get 78 days of hospice care. I felt like my only options were reduced pediatric care or full benefits using adult services. I wrote a letter of appeal stating that medically and ethically, neither of these were good choices. Well, we got a better outcome than I asked for. Not only will they cover the pediatric provider, but they have waived the lifetime maximum!

• If the insurance company is refusing coverage because they claim the procedure is "investigational" or "experimental" and therefore not covered, contact the Childhood Cancer Ombudsman Program for assistance. This organization offers a free service to help families maximize benefits or resolve disputes. In most cases, a detailed letter from your treating oncologist may help to resolve these issues.

• Contact your elected representative to the US Congress. All Senators and members of the House of Representatives have staff who help constituents with problems. You may also contact your state insurance board with concerns and complaints.

When I ran into insurance company problems, I wrote a letter to the insurance company detailing the facts, the decisions the insurance company made, and a logical explanation on why the procedure needed to happen. I also noted on the letter that a copy was going to our state insurance commissioner, and sent both letters by certified mail. Within two days, the insurance company all of a sudden decided to cover the procedure. I later found out that the insurance commissioner's office started an investigation against them. Letters help, especially when sent by certified mail.

• If all of the above steps do not resolve the dispute, take your claim to small claims court or hire an attorney skilled in insurance matters to sue the insurance company.

Above all, don't be afraid to ask questions, and be persistent!

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