Insurance Reimbursement

Receiving news that your insurance company has denied coverage for a necessary medical procedure or service, bandages, or supplies is a challenge many EB families unfortunately face.  Given many changes in the health insurance industry as well as the high costs of necessary services and supplies, a denial of coverage can bring additional stress upon EB families.  Described below is information to help families address instances where a health care denial has been received along with a sample letter which can be tailored to the specific instances of the insurance denial. 

Steps to appeal an insurance denial of claim for a health care service or item:

  1. Carefully review the insurance company letter explaining the reasoning for the denial of coverage. The letter will need to cite specific provisions of the insurance policy.
  2. Read the cited insurance policy provision to determine if the policy has complied with the promised coverage item or service. Insurance policies are written by industry professionals, which can make understanding of their practical effects difficult. Take your time in reviewing the language.
  3. If you determine, the policy has not complied, an ambiguity in the policy exists, or a reasonable argument can be made for the item or service to be covered, contact the insurance company on the phone to seek an immediate resolution.
  4. If no resolution can be accomplished over the phone, request instructions on where a written appeal can be sent and what needs to be included within the written appeal.
  5. Make sure to pay attention to the time frames the insurance company requires for complying with filing a written appeal.
  6. Keep good records of all communications with the insurance company including the date and time of all communications, and the names, positions, and contact information of all insurance company representatives. A good practice is to maintain a copy of all communications in either or both a computer folder or physical filing system for easy retrieval to review.
  7. Be persistent in checking back periodically on the status of your appeal. The squeaky wheel often gets the grease and more attention will be paid to your appeal if the insurance company observes you are paying great attention to your appeal.
  8. Keep Joe Murray, debra's Director of Legal Aid, in the loop if you need further assistance in seeking to resolve your denial of insurance claim.  We are here to help you develop a case for coverage of necessary services and items should your health insurance policy ultimately not approve the coverage.

Click here for debra of America’s Denial of Insurance Sample Letter.