Ten Steps to Protect the Legal Rights of Patients*
#1. Read your health insurance policy carefully.
If you have health insurance coverage through a private employer,
obtain a copy of both your Health Insurance Summary and a
copy of the Master Insurance Policy. Your employer is required
to provide you with a Summary of your health insurance plan
coverage. Your employer's human resources department will
have typically provided you with a Summary policy at the time
you signed up for the coverage. However, the Summary may not
include a detailed description of all of the covered benefits
and exclusions. Employers are often provided with a Master
Policy that goes into great detail regarding what is and what
is not covered. Under Federal law, your human resources department
and/or the insurer should provide you with a copy of the Master
Policy.It is essential that, if possible, you thoroughly review
both the summary and a copy of the Master Policy. If the two
policies are not the same, you may be able to use this in
an appeal, if one is necessary.
In reading the policy, look for references to the "plan
administrator." This information is typically at
the beginning of the policy and /or at the end of the policy. The plan administrator
may be an insurance
company or it may be your employer. This information is important because the
plan administrator
typically has the right to make the final decision about your coverage.
#2. Determine whether the treatment prescribed by your physician
is covered by your policy.
Check to see if there is an "exclusion clause" and/or an "experimental/
investigational" clause in the policy. This will give you
some indication of whether the treatment, for which you are
seeking approval, is excluded from coverage by your health
insurance carrier. Also, look at the definition of what treatments
are considered "medically necessary." Some treatments may
not be specifically covered by your health insurance policy.
If that appears to be the case and you need the treatment,
see a knowledgeable lawyer.
#3. Know your insurance policy appeal process.
After you have been denied coverage for the requested treatment,
make sure that you meet all the deadlines set by your insurance
carrier for appeals. In the first letter from the insurer
that denies coverage, check to see if the company has given
you a deadline by which an appeal or response from you is
to be received by the insurance company. If so, make sure
you respond by that deadline. All communications should be
in writing and sent by certified mail, return receipt requested.
Appeal procedures should be included in both the summary and
master policy. If it is a lengthy policy, the appeal procedures
may be hard to find. They are typically near the end of the
policy. Read your denial letter carefully. If it does not
include a deadline for an appeal and a description of each
stage of the appeal procedure, write to your insurer and request
that they immediately send you this information in writing.
Sometimes a deadline for an appeal may exist without your
knowledge. Stay on top of this and meet every deadline.
Remember, always communicate in writing!
#4. Obtain legal advice from an attorney who is knowledgeable
on health insurance issues.
It is essential that you have legal advice if you have been
denied coverage for treatment or services prescribed by your
treating physician. If your life or health is in jeopardy,
consult a knowledgeable professional as soon as possible.
While it is unfortunate, the reality is that a letter from
an attorney is often taken more seriously than a letter from
the person who is insured. Such a letter can often speed up
a reversal of a denial of coverage.
If you cannot afford a private attorney, there are pro bono
attorneys through the local Bar Association who may be available
to give you free advice. Just make sure the person from whom
you seek advice is knowledgeable about health insurance. Be
skeptical of any "professional" who has not worked in this
area before. In addition, do not wait until you have exhausted
all of your appeals before consulting an attorney. Often there
is little that can be done after the appeals process has been
exhausted.
#5. Plead your case in person to your insurance carrier.
If you can make a personal appeal to a Grievance Committee,
it is often more effective than a written appeal. Find out
who sits on the Grievance Committee. Ask if you may bring
your doctor with you and your lawyer. Again, having a knowledgeable
lawyer with you can only help your case. It demonstrates that
you are serious about protecting your rights and may help
to speed up the appeals process.
#6. Personalize your written case with your insurance company.
If you are not allowed to appear before a Grievance Committee,
submit your photograph, along with photographs of your family
and friends. You should also include letters from your family,
friends and clergy. Submit anything that will help to personalize
your case. Remember that you are fighting for your life and/or
health. Make sure that each person reading your case realizes
the personal impact and consequences of their individual and
collective decisions!
#7. Obtain copies of your medical records.
Make sure that you have legible copies of all your medical
records related to your current medical treatment. Also have
any correspondence between your physician and your health
insurance carrier. Make sure that your physician continues
to send you any correspondence between him/her and your insurance
carrier. Your physician may charge you for copies of your
medical records, but you are legally entitled to receive all
of your medical records.
#8. Document everything!
Document your telephone calls. Each time you speak with a
representative of your health insurance company, keep detailed
records including the date and time of the call, the person's
name, their title, their telephone number, their supervisor's
name and what was discussed. If the representative made any
promises or assurances, be sure you have an accurate record
of exactly what was said and send a letter confirming the
promises or assurances. If someone else is calling on your
behalf, make sure they also keep detailed notes.
#9. Ask your physician to advocate for your treatment.
Obtain an affidavit or a declaration from your treating physician
(and any specialists who have been called in for consultation
and/or treatment) that specifically describes your illness
and what is required to treat your illness. This statement
should also include a brief medical history, your prognosis
with and without the requested treatment, and a copy of the
treatment protocol, if applicable. Your physician(s) should
include, with the sworn statement, current copies of whatever
medical literature is available on your illness and the proposed
treatment. If possible, all of this information should be
sent to your insurance carrier with your first written appeal.
If a knowledgeable lawyer is helping you, make sure that you
sign a written release of your physician/patient privilege
so that the lawyer or his or her legal staff can discuss your
treatment with your physician(s).
#10. Be prepared to fight!
Your health may prevent you from being the best advocate for
your own treatment. Enlist the help of a friend or family
member, if you are not prepared mentally and/or physically
to fight for your appeal. Don't worry about being "nice" or
pleasing other people. You may have to be rude, persistent
and/or demanding. A knowledgeable legal professional can best
assist you with cutting through the red tape and delays that
you may face during an appeal. A lawyer will be able to file
your case in court, if that appears to be the only recourse
left to you following your appeals with the insurance company.
*This information is not a substitute for knowledgeable professional legal advice
based on the unique facts of your case. This information does not purport to
be, nor is it, legal advice.
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