With the high cost of medical care, it can be wildly frustrating when your health insurance denies a medication or treatment, or requires prior approval before agreeing to cover it. If you feel like you’re always fighting with your insurance company to get coverage for prescriptions, procedures, or tests, don’t worry, you’re definitely not alone.
That said, this battle can quickly become even more overwhelming, especially if you are recovering from or undergoing treatment for an illness, surgery, or injury. Fortunately, you have options. If your insurer is refusing to pay out their portion of your claim, you could have grounds for filing an appeal. If your medical claim was denied after a car accident, talk to a trusted Virginia Beach car accident lawyer from Shapiro, Washburn & Sharp today.
What Should I Do If My Insurance Company Denies My Medical Claim?
If your medical claim is denied, you can proceed in one of three ways:
- Ask for an explanation: Request details from your insurance company about why your claim was denied. If you disagree with their decision, you may have the right to file an appeal.
- Pay out of pocket: You can choose to cover the cost of the treatment or medication yourself.
- Decline the treatment or medication: You may decide not to move forward with the prescribed care.
If you disagree with the denial, there are steps you can take before you file an appeal.
If Possible, Get Pre-Authorization
If you’re planning to have surgery or an elective procedure, make sure your hospital or doctor gets pre-authorization from your insurance company before it’s done. Most providers can give you a copy of the approval for your records. Once the insurance company gives pre-authorization, they’re much more likely to cover the cost.
Know Your Policy
Sometimes a medical claim is denied because it isn’t covered by your policy. That’s why it’s important to go over your health insurance policy and understand what is, and isn’t, included. Familiarize yourself with the hospitals or doctors you are allowed to use, whether or not referrals are required, and which procedures need pre-authorization.
You also need to know your out-of-pocket costs and your deductible, so you aren’t caught unaware when medical bills start pouring in. Taking the time to review your policy and memorize important details can help you make good choices about your medical care. For example, if your insurance mainly works with one hospital system, it’s best to know that ahead of time.
Keep Copies of Medical Bills and EOBs
Once your insurance carrier receives your claim, they are legally required to mail you an Explanation of Benefits. The EOB outlines what was billed, what your insurance will pay, and what you still owe. If you don’t understand your EOB, or you disagree with it, contact your insurance agent right away.
A single phone call is usually all it takes to get your insurance carrier to pay its part of the claim. Once you get a customer service agent on the line, ask why your claim is not being paid in full. Ask for the name of the person you are talking to and take notes of your conversation. If you don’t agree with their decision regarding your claim, you might be eligible to file an appeal.
Remember that no two personal injury cases are the same. The best thing you can do in this situation is stay organized, keep records, and be patient.
How Do I File an Appeal?
If you believe your insurance company isn’t paying what it should, you have the right to appeal, and you should. Don’t assume the insurance company is always right. Some insurers deny claims, hoping people won’t challenge their decisions. Your policy and your Explanation of Benefits will explain how to start the appeal process.
- File on time: Appeals have strict deadlines, so check how long you have to submit yours. The first step is usually simple, but timing is important; file as soon as possible.
- Stay organized: Keep copies of your provider letters, medical records, and any communication from your insurance company. Be sure to enclose any and all relevant documents with your appeal. If it is denied a second time, you can request a review, wherein a doctor will evaluate whether or not your policy covers the test or treatment.
- Get help: Contact the state’s insurance department for advice on filing an appeal. Your hospital or doctor may also help, since they have an interest in making sure the claim gets paid.
- Don’t give up: It can, sometimes, take more than a single appeal to get the job done, but persistence pays off.
All We Do Is Injury Law
If you were hurt in a car accident in Virginia Beach, it’s important to talk to a lawyer as soon as possible. Insurance companies often do everything they can to avoid paying the full amount you need for medical bills and other losses.
The experienced Virginia Beach car accident lawyers at Shapiro, Washburn & Sharp can guide you through the process, handle communication and negotiations with insurance adjusters and medical providers, and help you avoid mistakes that could hurt your claim. In one case, our firm secured a $675,000 settlement for a client whose rear-end collision made a pre-existing condition worse and caused additional serious injuries.
To learn more or speak with an attorney about your case, call (833) 997-1774 or fill out the contact form on our website. Offices are conveniently located in Virginia Beach, Norfolk, Portsmouth, and Hampton.