Health Insurance Claims Resolving a Dispute in your Favor can be Simple

Resolving claim disputes can become a waking nightmare to the layperson who understands little about health insurance, attempting to translate legalese into English. Frustration escalates, tantamount to an all-out surrender. “I give up! What does this sentence mean?”

Normally, any injury or illness that begins after the commencement date of your insurance policy is covered. When you go to your physician, depending on the type of coverage you have, you will either pay a co-pay or a percentage of the total cost. Depending on the type of illness, your insurance carrier, such as Blue Cross/ Blue Shield, will request medical records from your physician in order to determine the onset of your illness.

Simple accidents, such as breaking a bone, do not usually come under close inspection, because, normally, people do not carry on every day business with an untreated broken bone.. There exists a tangible record of when the accident occurred. However, illnesses, such as heart disease, may have an early onset without noticeable symptoms. Cancer patients have an onset period, culminating in treatment, depending on the findings of blood tests and other forms of testing.

Patients are not always aware that any unusual symptoms are life-threatening unless the symptoms suddenly become unbearable, at which time they seek medical aid, thankful they have health insurance through their employer. If so, there is no cause for panic. You signed up during open enrollment, meaning your insurance carrier is duty bound, by law, to pay any and all claims relating to your health.

If a divorce has occurred, requiring new insurance coverage for the children, the coverage is considered a “special” enrollment, and it is also governed under open enrollment. Provide written proof of your divorce by sending copies of official documents. If the insurance carrier still refuses to pay your claims after several weeks of intense communication, the best method of handling the matter is by contacting your State Department of Commerce and Insurance, which is responsible for upholding and enforcing insurance laws in your state. Write a detailed letter in order to address the issue of non-payment of claims, enclose copies of all correspondence and the names of the individuals to whom you have spoken.

By law, the governing department will then investigate the matter, sending trained professionals to your insurance company, auditing the claims that have been submitted. If the insurance company is found to be at fault, the Department of Commerce and Insurance will fine them a hefty fee, as high as $10,000 to $50,000, depending on how often the carrier has been reported for attempting to bypass the law, forcing them to pay all claims without further question.

Once you have provided the correct information to the Department of Commerce and Insurance, do not attempt further communication with the insurance company. Let the professionals do their job, and relax. You will have done your best.