Merritt Personal Lines Manual: Pressing Health Care Claims
All the work you put into choosing the right kind of health insurance for you and your family comes to a point when you make a claim. Getting the best health care means understanding how your health plan works, what your rights are and how to complain if you need to.
It's important to remember that this is a process. Making a claim is like any other aspect of a contract transaction. The best companies will be supportive and understanding of what you've experienced. But what you really want is to have your claim paid.
When you do have to make a claim, don't be afraid to count on your agent, if you have one. Agents who are eager to keep your business can become your best advocates.
Although state laws vary on requiring consumers to make claims within a certain time period, most insurance companies prefer that claims be filed within 15 days or as soon as reasonably possible. If someone's been hurt in an accident, there's been serious damage or some law has been broken, call the police first. Then call your insurance company.
Your insurance company may grant you a little extra time if, for example, you're seriously injured and notice cannot be given within the listed time period. You can usually do this by calling the insurance company directly, through your lawyer or through your insurance agent.
Of course, insurance companies want to be notified as quickly as possible. And it's true that, the sooner you file a claim, the sooner you'll get a settlement.
"Once something happens, you need to let us know immediately, because we may need to investigate something, like tire tracks for example, which don't stay around very long," says one spokeswoman for State Farm Insurance Companies. "Know who you were in an accident with. Get the other party's insurance information, the number on the police report and the name of the person who's insured before calling us."
After the insurance company receives notice of your claim, it will usually furnish claims forms within a specified number of days.
Most states require insurance companies to either process a claim or at least tell you why it hasn't been processed, within 60 or 90 days. If it fails to do so, you may submit a written proof of the occurrence, character and extent of the loss either in the form of an official accident report or an affidavit.
If the company does send you the claims forms you can fill out a proof of loss and submit it within 90 days of the covered loss to be reimbursed. Once again, extra time is granted if it's not possible for you to respond within this time limit. But don't go over one year unless you're legally incapacitated because you may lose your opportunity to collect on a claim. Issues of incapacitation are less important than your forgetfulness and inaccuracy.
An important note: Remember to include all the expenses too. Most disputes over claims forms involve situations in which policyholders only include a portion of the expenses they've accrued. Then, when the insurance company only covers some of the bills, accusations start to fly.
Benefits are payable directly to you generally, medical insurance policies provide reimbursement for covered expenses. This means your insurance company wants you to pay your medical bills first and then it will pay you. Traditional insurance companies would rather not get involved with doctors or hospitals at all.
In the event of your death, the benefits may be paid to your estate.
Whether the benefits go to the estate or to an incapacitated person, the insurance company has the option of paying benefits of up to $1,000 to any relative who appears to be entitled to receive the funds.
Since your health insurance policy is a legal contract, the insurance company is obligated to pay the described benefits for all covered expenses under the policy. If your insurer doesn't live up to it's obligations, you have the right to sue them. However, no legal action may be taken against the company prior to 60 days after proof of loss has been furnished or more than three years after the date proof of loss is required to be furnished.
For example, you submit proof of loss for hospital bills. The insurance company doesn't deny the claim, but it doesn't pay it either. You get on with your life and four years pass before you realize the insurance company never reimbursed you. At this point, you can't sue the insurance company, because you've forfeited the right of legal action by taking too long.
While your claim is being verified, your insurance company also has the right at its own expense, of course to require you to submit to a physical examination. But, this typically comes up only in rare cases in which an insurance company suspects fraud.
One common error that can slow down the claims process is a misstated age on your insurance application. If this occurs, any benefits payable will be adjusted to the amount that the premium would have been, if purchased at the correct age.
This item usually governs situations in which older policyholders lie about their age in order to get cheaper premiums.
