Merritt Personal Lines Manual: Health Insurance -- Common Claims Issues, Disputes and Resolutions: Conclusion

When it comes to insurance, problems don't surface until you make a claim which is denied or underpaid.

Many of the same issues that influence how much a health coverage plan costs also influence how the same plan pays claims.

The main mistake people make when they have trouble getting a claim paid is that they assume the insurance company or managed care group has more authority than it really does. Insurance companies don't have any special power over policyholders -- both sides are simply parties to a contract.

That contract -- the insurance policy -- states how many issues will be resolved. Claims disputes are certainly one of those issues. But, within the parameters set by the contract, there is much room for negotiation and compromise. Much of the time, the insurance company or managed care group is counting on that room to work to its advantage -- after all, it employs people who spend their days reading and enforcing insurance contracts.

But there's room in the contract for you, the policyholder, too. If you don't like the fact...or the manner in which...a claim was denied, you can press your issue. Your pressure will usually need to start within the insurance company's own appeals process. If that doesn't accomplish anything, you can press on to regulatory agencies.

The important thing to remember is that insurance companies are in business to make a profit. This will usually give them -- despite how their employees may act -- an impulse to settle disputes that they can't avoid. If your position is well-reasoned and consistently made, you may get more satisfaction than you'll first expect.