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ISSUED 08/11/2008 FOR IMMEDIATE RELEASE

Consumer Protection

WHAT TO DO IF YOUR HEALTH INSURANCE COMPANY DENIES A CLAIM

By Eric Dinallo
Superintendent of the New York State Insurance Department

Major illness or a stay in the hospital is always stressful. It's not a time you want to be worried about your insurance coverage. For some consumers, however, this is when they learn their insurance company won't pay part or sometimes all of a claim.

To help understand your options when a claim is denied, the New York State Department of Insurance suggests these steps:

  • Read and Understand Your Policy – The policy is a legal contract, so understand your rights and responsibilities. It will list the benefits the insurance company will and will not cover. If anything is unclear, get clarification from your insurance agent or company. If you are insured by a group policy through an employer, you will receive a certificate of coverage. The certificate of coverage will list benefits and your rights and responsibilities. Know which services require authorization prior to the treatment or service being obtained. Failure to obtain prior authorization will most likely result in a denial. Services that commonly require prior authorization include such procedures as elective surgery and MRIs.
  • What to Do if a Claim is Denied During Treatment – Contact your insurance company immediately. Keep notes of all conversations. Include the name of the person with whom you speak and the date and time of the conversation. Listen carefully and make note of the answers you get. In addition, check your policy or certificate of coverage to determine your appeal or grievance rights. Make note of time frames in which you must appeal a decision. Be sure that you do not exceed any time limits.
  • Be Persistent – Sometimes a simple error may have caused a denial. A billing error or incorrect code may have been entered. This type of error can often be cleared up quickly. If, after your initial conversation with the company, your claim is refused, be persistent.

    Insurers and HMOs are required by law to provide a written explanation of benefits (EOB) which must include a specific explanation of any denial, reduction or other reason for not providing full reimbursement. The EOB must also include a telephone number or address where an insured can obtain information on how to file an appeal. An appeal should be filed as soon as possible; don’t wait because there are specific deadlines within which an appeal must be filed.

  • What to Do If an Insurer Continues to Deny a Claim – Generally, you should first submit a letter to the company requesting that your claim be reconsidered, giving specific reasons why you believe the claim should be paid. Be as detailed as possible, explaining why your procedure or medication is needed. Make arrangements with your medical provider to have medical records, x-rays or lab results sent to the insurer to support your position. Be sure to keep a copy of everything for your records. Your insurer must respond, indicating the next steps in the process.
  • Know Your Rights – If a health insurer denies or limits a medical service because it is considered experimental, investigational or not medically necessary, you have a right to appeal the decision. Request the insurer conduct an internal appeal to reconsider its decision. If you disagree with the result, contact the Insurance Department and request an external appeal conducted by a medical professional not affiliated with the insurer. You must request an external appeal within 45 days of the insurer’s decision on the internal appeal. The Insurance Department will review your request for an external appeal within five business days and, if the request is eligible and complete, assign an external appeal agent to review the matter. A decision will be made within 30 days. There are provisions which allow for an expedited appeal if the services have not yet been provided and a delay in providing them would pose an imminent or serious threat to the patient’s health. A decision on an expedited appeal must be made within three days.

More Information

Contact the Insurance Department’s Consumer Services Bureau if you are unable to resolve a dispute and need help to do so. The Bureau can be reached between 9 a.m. and 4:30 p.m., Monday through Friday toll-free at 800-342-3736. On-line complaints may be filed at any time on Department’s Web site, www.ins.state.ny.us. In addition, the Bureau has a dedicated toll-free line for questions relating to experimental, investigational or medical necessity denials. Consumers should call 800-400-8882 with questions relating to these types of denials.

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