Many of us are familiar with the “headache” of receiving a denial of coverage notice from a health insurance company for medicines or other treatments prescribed by the doctor. Even though the health insurance company may deem your treatment unnecessary or experimental, such determinations are not final. You do not have to accept NO from your insurance provider! But how do you turn that no into a yes?
Health insurance companies anticipate these disputes over coverage denials and must have a process in place for you to appeal your denial. Be sure to check your insurance agreement for the steps necessary for making that appeal. Also, be sure to consult your doctor. No one knows better than your doctor why you need the treatments which he prescribed. Your doctor can be a highly effective advocate on your behalf.
If you are unable to settle your dispute by working through your insurance company’s appeal process, you may wish to consider filing a grievance or a lawsuit.
You may file a grievance with the New York State Commissioner of Insurance in Albany. In more significant cases, where the company’s denial has caused you to experience further harm, a lawsuit may be in order.
You can sue your health insurance company for breach of contract.
Often a denial of coverage is unreasonable on its face and is merely a pretext for the health insurance company to save money by making as few payments as possible. An experienced attorney at Lipsitz, Ponterio & Comerford can help you determine the merits of your claim.