The Language of Health Insurance Companies & Claims
Part 1: The Basic Tools, Chapter 2: Understanding the Language of Health Insurance Page 2
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When I reviewed the statements from the insurer explaining why the claims had been denied, I noticed that the company had requested a copy of an accident report. Since that seemed to be a particularly odd request, given the nature of the treat ment, I called a supervisor at the insurance company. As I reviewed the case with the supervisor, I discovered that the consumer had written the word "therapy" on the claim form under "Type of Illness or Treatment."
Some insurance companies -- including the company in volved in processing this particular claim -- use the term "Therapy" to refer only to physical therapy. Therapy sessions with a psychologist or psychiatrist to treat mental or emotional illnesses are generally referred to technically as "outpatient treatment for mental illness." When the claims processor saw the word "therapy" on the claim form, she had apparently assumed that the claim involved physical therapy. She then requested an accident report, on the assumption that the need for physical therapy was the result of an accident.
In the meantime, the claims were temporarily denied, pending the receipt of either an accident report or a letter of expla nation confirming that the physical therapy was not related to an accident. When the claims were re-filed with the phrase "outpatient treatment for mental illness" instead of "therapy" written under "Type of Illness or Treatment" on the claim form, they were paid without difficulty.
Many health insurance claim problems turn out to be the result of similar misunderstandings related to the use of tech nical terms and phrases. In order to communicate effectively with an insurer, or to understand the letters or statements that insurers send to consumers, it's often necessary to understand that terminology.
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