How To Beat Insurance Companies, Legally

Blog#226-12/15/24

HOW TO BEAT INSURANCE COMPANIES, LEGALLY
By
Richard Davis

Many of us consider health insurance companies to be the enemy. They have too much control over our lives and we feel frustrated having to pay high prices for premiums and then not being sure if our insurance will even cover us when we need it. Sadly, one person recently took his outrage on an insurance company CEO by killing him. That doesn’t make matters better. If that murderer wanted to change the system he could have done a lot of other things, but he chose to make headlines the wrong way.

Short of creating a single payer system where private insurance companies are eliminated, there are a few ways to rein them in and get what you need. One of those ways is to go through the appeals process when a claim for service is denied. Every state has different rules about how to appeal denied claims and I will talk about how to beat the big boys in Vermont. I have helped people with appeals over the years and have won appeals against Blue Cross Blue Shield of Vermont three times.

This process is not for people who do not have the patience to make a lot of phone calls and deal with a lot of people who try to make it hard for you to do what you want. You have to hang in there and, in the end, you will have a good chance of winning. You first have to file an appeal directly with your insurance company. They try to wear you out early on and hope you give up when they make you jump through a lot of hoops. If your appeal is denied then Vermont has a mechanism for you to request an external appeal.

An external appeal must be filed within 120 days or four months (whichever is longer) of receiving the final denial letter from your insurer. An appeal is filed through the Department of Financial Regulation in Vermont and if you go to their web site it will give you details on the process. Most people find this process too daunting and they usually give up early on or, if they can afford it, they hire a lawyer to help them.

It was more than 30 years ago when I first went up against Blue Cross to help a Newfane woman get treatment for advanced breast cancer. At the time Peter Welch, our current Vermont junior Senator, was just a lawyer in private practice. Welch offered to help with the case pro bono. I don’t remember if I contacted him or she did but he dug right in and we all worked together. Blue Cross claimed the treatment she was seeking was experimental. We were able to prove it was accepted practice and not experimental. She got the treatment but, sadly, died after a short time. But the satisfaction of beating the big boys, I am sure, boosted her immune system enough to give her a few extra quality days.

According to the Department of Financial Regulation:

To qualify for an independent external appeal, the insurer must have denied coverage for one of the following reasons:
• The service is not medically necessary, or
• The selection of a health care provider is limited in a way that is not allowed by your contract or by law, or
• The service is considered to be experimental, investigational, or an “off-label” use of a drug, or
• A medically based decision was made that your condition was “pre-existing”, and
• Was a covered benefit under you plan.

If it appears that you qualify, you may complete the attached application or ask us to send you an application. There is a $25 filing fee that may be waived. We will collect documents from you and the insurer and submit them to the Independent Review Organization (IRO). Decisions by the IRO are made within 30 days of receiving all information.

Note: A medical provider can submit an appeal form on a patient’s behalf; however, the patient must sign it beforehand.”

During my appeals I went head to head with the Blue Cross medical director. An expert in the field relating to the appeal is hired by the state to mediate. Each side presents its case and then waits for a decision. It is important to note that you still may have to follow up after you win to make sure the insurer pays a bill or provides the service.

More than 50% of appeals of coverage denial are successful. There are few things more satisfying than beating the big boys. But we should not have to fight so hard for care that we are paying for. Welcome to the U.S. health care system.