Tips for fighting an insurance claim

By Colleen LaMay

You can ask your health insurer to reconsider if it rejects a claim or refuses to pay for treatment you consider medically necessary. In 2005, Blue Cross of Idaho processed 838 such appeals from patients or their families, ruling in members’ favor in 328, or more than one-third, of the cases, said Tod McKay, public relations manager at Blue Cross.

Here are the rules Blue Cross of Idaho says it follows:

Call or write the company to notify it of the problem, McKay said. Next, Blue Cross needs all the medical documents from your doctor or hospital that will help the company’s medical-review team decide your case. Under state law, the company must decide your case within 30 to 45 days, unless it needs more time to get your medical records. The average turnaround time at Blue Cross is much shorter, just 17 days, McKay said.

If you don’t like the company’s answer, you can try twice more, getting more documentation to back your case. Except in extremely rare cases, the company will not approve payment for treatments it considers investigational or experimental. The third appeal is for cases involving those issues, which go to an independent physician review organization with no ties to the insurer.

Regence BlueShield of Idaho outlined a similar three-appeal process to Blue Cross in an e-mail. If the answer from either insurer still is no and you remain convinced it should be yes, you can take your case to the state Department of Insurance. Call 334-4250.

"We encourage consumers to call us," said Gina McBride, supervisor of consumer affairs for the department. "Call and ask questions and then they can decide whether they want to work the complaint process with us." The department gets about 800 consumer calls about health, life and other insurance each month, down a bit from recent years. About 10 percent of callers go on to file complaints, McBride said.

Some cases are easy, like helping a patient get necessary records from a health-care provider. Others are tougher. Determining medical necessity usually is beyond the scope of the department, unless a company has obviously breached the terms of its customers’ policies. And it rarely can do much about rate increases.

Lately, more people are complaining about prescription drugs. Their insurer may not pay for a drug their doctor recommends. The department is deciding how to proceed in those cases. "We are still looking at that and shaking our heads," she said.

The department does not provide legal advice, but some people who file complaints go on to hire attorneys.

You can file a complaint with the department one of two ways:
- Send a letter to Idaho Department of Insurance, Attention: Consumer Assistance, P. O. Box 83720, Boise, ID 83720-0043
- File online at the department’s Web site

Provide as much information as you can about the situation, including policy numbers, company name and details of the situation. The more information the department has, the faster it can help you.