People who are denied a Critical Illness claim are often successful when they appeal, but it takes medical evidence, persistence – and some help.
Most people don’t appeal an insurer’s claim denial, even though it can be done successfully.
Successful appeals require an understanding of the claims examination process and how to trigger an insurer to agree.
Patients can appeal denials for critical illness claims with the help of an advocate specialist.
Appeal a Critical Illness Claim Denial
When most people get a “your claim has been denied” letter from their critical illness insurer, they have a similar reaction: They give up. The insurer is like Goliath to their David – they’re too big and too determined not to pay.
But what they don’t know is that when people appeal the claim denial – which they are allowed to do – they often win.
Every critical illness claim goes through a process known as an examination. This involves a review of medical records, an attending physician’s report and policy language evaluation. Insurers don’t share their examination efforts with insureds, and in many cases are advised not to assist a claimant.
When a critical illness claim is denied the reason is most often that the medical event isn’t covered by the Policy or the insurer doesn’t consider the resulting condition severe enough to trigger a benefit.
Yet few people challenge denials. Most people take their denial to an attorney, the attorney doesn’t want their case, and they give up. In fact, what’s needed when a claim is denied is a critical illness claim specialist. These advocates understand how to get a claim triggered and will pursue the claim on behalf of the insured for a fraction of the cost of an attorney.
Critical Illness Claim Advocates
While most people only think of health care advocates, there are those who specialize in critical illness insurance. Where healthcare advocacy is typically focused on assisting patients with understanding a host of health related items (think decision making, health coaching, resource alignment), a critical illness claim advocate is focused on getting the patient’s insurer to approve a maximum claim benefit for the condition diagnosed.
Some keys to an advocate’s success are examining the claim in a more thorough way than the insurers’ examiner and getting detailed medical opinions. Precisely addressing the insurers’ objections, backing up the new argument with medical facts and authoritative evidence can take a denied claim to approved.
Here are some steps Critical Illness claim experts say patients should take to overturn a denied claim.
1. Pay attention to the claim denial letter
The Denial letter is probably vague, but it does provide some information about the reason the claim was denied. Insurers instruct their examiners not to help claimants file successful claims, but they are obligated to give the basis for their denial decision. A good appeal letter addresses every basis for the denial.
When preparing an appeal letter as much medical evidence as possible that supports approval of the claim should be included. This may require a bit of research, but the stakes are high so the effort is justified.
2. Seek help from your doctor
Getting an amended statement from a physician about the diagnosis is also a good idea. A physician shouldn’t give an opinion about the insurance coverage, just about the diagnosis and prognosis.
An appeal that relies on a doctor’s opinion about what is covered under the policy will fail. Insurers aren’t interested in a doctor giving an opinion about a contract – only about medical conditions.
Often, insurers will rely more on their own in-house doctor than the patient’s treating doctor. This raises an obvious conflict, but again, it can be overcome. By including multiple sources of medical facts that support the critical illness claim, the insurers doctor will be hard pressed to object.
3. Use all resources available
A claim advocate will be well versed in the methods of a successful critical illness claim appeal. They, along with medical publications, physician statements, nurses, therapists, specialists like oncologists and cardiologists and, of course, attending physicians, dramatically increase the chances that an appeal will be successful.
