Video: All you need to know on heath insurance

By Health editor
updated 8/15/2007 8:47:49 AM ET 2007-08-15T12:47:49

You battle to get healthy when you’re sick, diligently arming yourself with medication, surgeries and doctors’ visits in the war against disease. But, for many, there’s another unexpected fight — a battle against health insurance companies who may refuse to pay for crucial treatment or may even drop you entirely.

When it comes to health insurance, what you don’t know can hurt you, so the best time to make sure you’re really covered is before you become ill. Taking some simple measures now can help prevent problems later.

To find out what you need to know about your health insurance but probably don’t, turned to two experts.

Rhonda Orin is the managing partner of the Washington, D.C., law office of Anderson, Kill & Olick, P.C. and represents policyholders in disputes with health insurance companies. She is also the author of “Making Them Pay.”

William Shernoff is the senior partner of Shernoff Bidart Darras, a Claremont, Calif.-based law firm that represents insurance policyholders. He’s the author of three books, including “Payment Refused.”

Don’t fall victim to ‘secret program’
A surprising number of patients have been in the middle of costly treatment for a serious disease only to have their policies canceled, sometimes even retroactively, and found themselves responsible for astronomical bills. It’s called rescission.

“It’s a secret program that if you have a serious illness … or are on costly medications, when they get the bills, they go through [your file] and look at your application … and get medical records from the last several years. And if they find an inconsistency in your application, even if it’s an honest mistake, your policy is rescinded,” says Shernoff. “It’s a very harsh punishment visited upon a lot of people.”

Shernoff represented plaintiffs in a class action suit against Blue Cross in California that resulted in the company being fined $1 million in March 2007 for rescinding 6,000 policies without proving that patients willfully falsified their applications.

Fact fileTo keep it from happening to you, be very careful when you fill out applications, warns Shernoff.

Answer the questions as best you can. And if you’re not sure if you’ve had a certain condition or treatment, write down that you don’t remember, he says. Most forms don’t allow space for that answer, so be prepared to have to squeeze it in.

How to keep from getting denied
Some insurance companies will veto a doctor’s orders if they feel the treatment isn’t necessary or consider it experimental, says Shernoff. “They do a lot of denial for newer treatments, especially cancer treatments.”

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Try to get treatment preapproved if you have any question about whether it’ll be covered. But that can also send a warning sign to the insurance provider.

“Preapproval is often what triggers the rescission review,” says Shernoff. “If it’s for hip surgery, that’s an expensive item that they’ll look at and see if you’re a candidate for rescission.

“I think that's why people are so frustrated in that there's not a lot you can do to avoid getting caught up in these denial programs,” Shernoff adds.

What you can do, he recommends in his book “Payment Refused,” is make sure you read your policy carefully and follow exactly the steps your insurance company requires for filing a claim.

Orin emphasizes playing by the insurance company’s rules. Make sure you know what is covered, she advises in her book, so when you call for preapproval you can say with authority that you’ve checked and have met the criteria for a particular procedure.

How to appeal a decision
If you’ve been denied coverage for a claim, you can appeal to the insurance company, your state’s department of insurance or you can file a lawsuit, says Shernoff.

If you appeal to the company, know that it usually goes to the medical director, who is an employee of the insurance group, he notes.

Have your doctor write a letter explaining why it was a necessary procedure. If possible, include journal articles showing the effectiveness of the treatment. The key is to get the doctor to make a stronger case than the insurance company has and make it hard for them to say it’s not medically necessary.

Insurance companies don’t like lawsuits, he says, but most patients don’t like to get involved in litigation.

“You’re trying to get well and going through chemo and it’s not the time for you to be fighting your company. Bills don’t get paid and you get turned over to collections and your credit is getting ruined,” he says. “It’s tragic and outrageous … ”

What your state says insurance must cover
Many people don’t know that each state has a mandate of treatments that forces health plans to cover certain treatments, regardless of what the insurance company policy is, says Orin.

Slideshow: Perspectives on health care Some mandates, reprinted in Orin’s book “Making Them Pay,” ordered coverage for some surprising things, including infertility expenses (Illinois, Montana, New York and other states), toupees and wigs for cancer patients (Massachusetts), surgery for morbid obesity (Indiana), cochlear implants (Kentucky) and baseline testing for lead poisoning in children (Delaware).

Orin’s book collects mandates from the year 2000 for all 50 states, but to get current information, she suggests visiting the Web site of your state department of insurance.

Not everyone is eligible under the mandates, but if you purchase your policy independently, you definitely are, says Orin. If you purchase it through your work, you might be.

Find safety in numbers
Very few policies are rescinded if people are in a group. “There’s more bargaining power,” Shernoff explains.

People are also less likely to have a claim denied if they’re part of a group. If that happens, unhappy policyholders employed at corporations can complain to human resources. And if the employer feels the employees aren’t being well taken care of, it may decide to choose a different insurance company instead.

Individuals who can’t get coverage through an employer should look for a group to join, such as the AARP or an association affiliated with your job. (Occupations ranging from fitness trainers to trial lawyers have associations that offer group insurance.)

Do everything in writing
Orin advises conducting exchanges in writing via fax, snail mail or e-mail if you can find an address. Try not to do anything over the phone. “It’s frustrating, it takes forever and when you hang up, it didn’t happen,” she says.

If you do have to have a conversation by phone, get the customer service representative’s name and phone number and listen for the sound of them typing to make a record of your call.

Try not to get too emotional
If a claim has been turned down or you feel an error has been made, treat it like you’re the bookkeeper for a company and that you have to make sure the bill is paid, suggests Orin.

Read the insurance forms to make sure you know what is getting covered and what isn’t.

“To catch that mistake, you have to have some sense of what’s going on in the first place,” she says. “Don’t assume everyone else is right and you are wrong.”

Scrutinize the fine print
Some health insurance companies advertise to attract small mom-and-pop business, Shernoff says. While at first it may look like the policy covers major medical costs, the fine print may reveal that’s not necessarily true.

“You have to be really careful to find out what the benefits really are,” he says.

That includes learning what the insurance company is willing to pay for procedures. Some policies say they cover 80 percent of “reasonable customary charges.” But if a doctor submits a bill for $20,000 worth of treatment, the company could claim that’s not a reasonable charge.

Lastly, keep your records
Make sure you hang on to the records of your correspondence and other documents, Orin advises.

Even once your claim has been paid, it’s a good idea to keep to the paperwork for three or four years, she says.

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