You have cancer and now you need to add a new battle, with your insurance company because they have denied your request to cover a certain drug or a treatment. Going to your health insurer is always frustrating and time-consuming. They don’t care if what you need will extend your life or make living better, they don’t want to pay. Yes, you pay absorbent premiums each month, but they don’t want to part with your money.
Sometimes you need to appeal a coverage denial. Appealing their decisions, as they are the initial judge and jury, can make you want to tear your hair out, but it is what you need to do to protect yourself and get what you need. There are several strategies that can bolster your case and improve your chance to beat them.
The very easiest problem to solve comes from your doctor’s error when a wrong code on a claim form is entered. This type of error can be resolved with a phone call. This is the easiest issue to solve; other issues can be more difficult.
These more difficult issues bring in complex medical questions like whether a certain cancer treatment is appropriate for you and if one treatment may be superior to another.
Your first task is to learn your insurer’s procedure for appeals and to specifically find out what led to the denial. Calling your insurer on the phone is best. Always take notes, include the names of everyone who speaks with you and what they tell you.
Request some key documents to reconstruct what led to the denial. Get a copy of the denial letter, a copy of your plan’s full benefits language, sometimes called the “Evidence of Coverage,” as well as the detailed guidelines that explain what the company considers medically