Life Insurance

A denied claim is not final; so, take a deep breath, relax, sit down, and get a cup of coffee. This article might be just what you need to guide you in finding solutions to your unpaid medical claim.

Gathering of information

Collect all documents that are relevant to your medical claim; such as, you insurance policy, denied claim, letters that you received from your doctor and the insurance company and many more.

Examine and understand the claim rejection reason

Read the claim EOB (Explanation of Benefits) sent by your insurer because you will see there what the rejection reason was. Most of the time a claim will be denied because of the following:

• Errors in submission of claim forms such as the doctor’s office failed to use the correct or registered NPI (National Provider Number), incorrect claim form used, wrong place of service used for the procedure, wrong diagnosis code and many more. In cases such as this, the doctor’s office only has to file a corrected claim so that your medical claim will be adjusted and paid.

• Denied due to preexisting condition. The insurer will send you a letter requesting for the list of medical providers that you have seen for a specific time frame; so that they can contact your medical providers. Request for your medical records and the review department will conduct a preexisting review. If they find out that the diagnosis for the medical procedure performed is indeed one of your preexisting conditions that fall under the preexisting waiting period, your claim will receive a final denial. Usually, some claims are pended for preexisting review for months because the insurer is still waiting for the response of the member to the letter of the request or for the medical records.

• Denied due to precertification. This means to say that the medical service performed is a covered service; howeve, approval should be obtained before it can be performed. The facility or doctor’s office has to call the precertification department of the insurance before performing the service. Usually services that require approval are 24 hours inpatient stays, expensive diagnostic services such as MRI and CAT scans, mental health services and expensive durable medical equipments. If for some reason, no precertification was obtained for the procedure or equipment, your medical provider can call the precertification department and get a retroactive precertification and re-file the claim.

• Denied due to no predetermination. It is a procedure where a medical provider with the member’s request/approval would send the insurer the member patient’s medical records and recommended medical tests, medical equipments and treatments for non-emergency procedures that are usually very expensive such as breast reconstruction and bariatric surgery.

• Denied due to timely filing. Claim timely filing limits vary depending if the medical procedure was performed by a non-contracted provider and which state you are located. Usually it is six months from that the date of service. It could be that your medical provider sent the claim before the timely filing limit, there was a computer glitch in the insurer’s system, and they only received the refilled claim. So do take the time to speak to your provider and know when was the first time they filed the claim. You can request them to re-file the claim if they can show a copy or proof of timely filing.

• Denied due to eligibility. This usually happens to newborn babies who are not yet added to the policy. Just call your insurance representative and have the claim adjusted over the phone. A newborn is covered under the mother’s policy for the first 30 days from birth for most states. (more…)

You have worked hard your whole career, but now you find yourself unable to practice your profession because of a physical or mental disability. You’re not alone. In fact, some statistics indicate that a person in their mid-thirties has a 50:50 chance of experiencing a disabling condition that prevents them from working for at least three months before they retire. In addition, one out of seven workers will become disabled for a period of more than five years before reaching retirement.

Luckily, you were wise enough to purchase disability insurance to offset the risk that you would become disabled. Unfortunately, however, disability insurance companies have developed a sophisticated system to maximize profits and avoiding paying your claim, regardless of the merits of your condition. How can you avoid having your disability insurance claim denied or terminated?

Among the many hurdles you will likely face when filing a claim for disability insurance benefits are:

• Understanding, interpreting, and correctly following the terms of complex policies drafted by insurance companies;
• Recognizing, avoiding, and dealing with insurance companies’ efforts to wear out claimants by delaying the claim process;
• Ensuring that treating physicians take the time and effort to document the disability sufficiently and in a manner that is helpful to your claim;
• Avoiding insurance companies’ attempts to use out-of-context secret surveillance as a basis for terminating or denying your disability insurance claim;
• Ensuring that independent medical and psychological evaluations are conducted appropriately, fairly, and without risking injury;
• Fighting insurance companies’ attempts to terminate or deny disability insurance claims simply because the symptoms of your condition are subjective or self-reported;
• Overcoming the great number of other techniques and tools that insurance companies have developed to engineer a basis for denying legitimate disability insurance claims, because their primary goal is profit.

Complex and Confusing Insurance Policy Language

The language of every insurance policy is complex and confusing, drafted by attorneys and insurance company employees with an eye towards protecting their own interests. When denying or terminating a claim, insurance companies capitalize on the complexity of their policies at the expense of the insured. The truth is that there is no “standard” insurance policy contract, and the provisions vary dramatically from policy to policy, where coverage is usually circumscribed and restricted with different qualifying words and phrases. In order to overcome the insurance companies efforts to use jargon and legalese to avoid paying claims, it is crucial that a claimant understand the specific definitions of the key terms and phrases in the policy, and also the ambiguities in those words. When words or phrases are ambiguous or their meaning is not clear, courts will construe the meaning of those terms against the drafter (the insurance company) and in favor of the other party (the claimant). Having a thorough understanding of your policy language may be the most important step to filing your disability insurance claim. (more…)

If you ever have to file a home business insurance claim, take steps to ensure the process goes smoothly. Provide your insurer with as much information as necessary to ensure payout. Carefully read the details of your insurance policy when you purchase it and look over the policy again before you file a claim.

The first thing you need to do is call the police or fire department if the damage was caused by an accident, fire, fraud, theft or vandalism. A police report and other necessary documents need to be on file. Next, contact your insurer and relay the problem. Gather receipts and any other documents that demonstrate proof of ownership. It is strongly recommended that you maintain copies of business records such as assets and inventory in a safe place, preferably off-site. You will need access to these documents if your home business incurs loss or damage or a lawsuit is filed against your business.

Have professionals assess and repair the damage as soon as possible. Obtain at least two or three repair estimates from reputable sources. Typically, you do not need authorization from your insurer to make emergency repairs that ensure the business is safe and operational. Keep in mind the insurer needs to see receipts for repair parts and services.

Consider having an attorney prepare the insurance claim. Attorneys who specialize in insurance claims know the information an adjuster needs to settle the claim. It is also a good idea to obtain legal counsel if the claims process stall due to a dispute.

If you plan to file an interruption of business claim, expect to show the level of income your business was generating before and after the loss. Maintain detailed records of all your business activity, including any expenses you incur while operating out of temporary location. Also note recurring expenses like phone and utilities if you must temporarily close or shut down service.

Establish a specific timeframe for the claims process. Neglecting to follow up may result in a claim delay. Keep in close contact with your insurance representative if you feel the claims process is not progressing fast enough. File a complaint with the insurance company if you think the claim has stalled. Try contacting your state department if you continue to have problems with the insurance company. Contact an attorney if you would like to pursue legal action. (more…)