Health Administration Responsibility Project
"Fight Back & Win"
by William Shernoff Esq.
Legal tips to follow if your claim is denied
- Insist on a written explanation of your denial.
Don't accept a filing error as grounds for refusal. The insurer must show it has been harmed.
- Create a Paper Trail with names of everyone you talked to and copies of all correspondence.
Set up a folder and a calendar to track when responses are due.
- Always communicate with your HMO by registered mail.
- Telephone the claims examiner. Move up the chain of command as necessary.
- File an immediate appeal, per the plan's grievance procedure.
Remember that you have the right to bypass the HMO's internal grievance procedure.
- Follow up every phone conversation with a letter stating your complaint again.
Include your name, member ID number, copies of bills, tests results, doctors' statements, etc.
Clearly state what you want the HMO to do.
Request a written response within 30 days.
Always include the sentence:
This appeal relates only to the denial of the benefits in question,
but does not constitute, and in no way shall be deemed, an admission
that I am limited in my right to pursue a "bad faith" remedy in state court.
- Ask your doctor to write the HMO on your behalf.
- Get a second or third opinion from a qualified professional outside the HMO network.
- File a complaint with your state regulators (Dept. of Managed Health Care in Calif.).
Include copies of your correspondence with the HMO.
Let your HMO know that you're contacting the regulators.
- Enlist the help of consumer organizations, the media, and your elected representatives.
- File a complaint with the State Medical Board if you think your doctor is withholding treatment for
his own personal gain.
- If you receive your insurance through your employer, notify the company's Human Resources
deoartment of your dissatisfaction. Enlist you group policy administrator.
- Consider small claims court if the amount is under the dollar limit.
- Hire a "bad faith" lawyer on a contingency basis, if necessary.
- Never give up! Be persistent! The HMOs depend on your passivity.
Insurance traps that can effectively cancel your insurance
- Custodial Care Exclusions
Insurers will categorize nursing care as 'custodial' to reduce their costs.
They will invoke this in cases of catastrophic accidents requiring intensive care,
where the patient isn't expected to recover.
- Experimental treatment exclusions
Insurers may invoke this exclusion even for accepted treatments which are expensive.
Some may invoke it, even without an explicit exclusion, claiming that experimental
treatments are therefore not "medical"
- Narrow Definitions can drastically limit coverage.
For example, defining a 'hospital' as an 'acute care facility' may effectively exclude
coverage for extended care and rehabilitation hospitals
- Limits of Liability
Limits may be much lower than typical charges.
Some policies may pay nothing till after, say, 7 days.
Some require a "qualifying" stay in an acute care facility before paying anything
for skilled nursing care.
- Major medical policies that pay "hospital charges".
Much expensive treatment, like chemo- or radiation-therapy, is given as an outpatient,
and wouldn't be covered.
- "Medical Necessity"
These decisions are often made by bureaucrats who never see the patient.
Try to get treatments "pre-authorized" when possible.
- "Reasonable and customary" charges
Insurers often use outdated or otherwise irrelevant fee schedules to underpay.
Canvas the doctors in your area to get truer figures.
- Exclusion if patient becomes Medicare Eligible.
Anyone who becomes disabled becomes eligible for medicare. This exclusion lets the
insurer off the hook, and throws the patient entirely upon medicare.
Please send comments, suggestions and relevant citations to