Merritt Personal Lines Manual: What to Do If the Company Denies A Claim
If your insurance company denies your claim, ask why the claim was rejected. If the company's answer involves a service that isn't covered under your policy (and you're more than certain it is covered), check the claim form. It could be that the provider entered an incorrect diagnosis or procedure code. You might also want to check that your deductible was correctly calculated or that you didn't skip an essential part of the process.
If everything still seems to be in order, you can then ask your insurance company to review the claim.
For cases like these, it often helps to keep written records of the following:
- All correspondence with the plan.
- Claims forms and copies of bills.
- Phone conversations -- the date and time, the people you speak with and the nature of each call.
If the insurance company still denies your claim or insists you take it to court for your money, don't be intimidated. Ask for the language in your policy or in state law that allows it to deny your claim. Save all paperwork and log all phone conversations with company representatives.
If what your insurance company says doesn't agree with your reading of your policy, ask your state regulator. While state insurance commissioners usually have no legal authority to force an insurance company to pay an individual claim, the commissioner can fine a company or take other punitive actions if an insurance company makes a practice of unfairly underpaying or denying claims.
Most health plans have some sort of appeals process that you and your doctor may use if you disagree with the health plan's decisions. If your plan refuses to provide or pay for services, you can complain or file a grievance about any decision you feel is unfair -- or you can appeal it.
