What if insurance denies a claim?

If you think that the insurance company has denied a claim that should have been covered or is discontinuing coverage, first contact the patient’s insurance company and/or human resources department if health insurance is provided via her workplace. Sometimes simple changes need to be made to fix the problem. For example, claims can be rejected for reasons such as having your incorrect birth date or social security number (SSN) in the computer system or on a form.

If an initial telephone inquiry does not work, write a letter to the insurance carrier, clearly stating the claim number, the date of service, the correct personal information of the patient (policy and group numbers, SSN, birth date, name, and address), and the reason you believe the claim should have been approved. Be direct but pleasant in your tone, and keep a copy of the letter. The carrier may request additional medical information before covering certain tests or treatments, and sometimes sending additional documentation or having the doctor contact the carrier can resolve these issues. If you have exhausted all other options, you can contact your state’s insurance commissioner or hire a lawyer who specializes in insurance disputes.

Recent legislation at the state and national level exists to protect patients, in some limited ways, from insurance coverage lapses due to medical diagnosis and unfair claim rejections. Private insurance companies and health maintenance organizations (HMOs) are most likely regulated by your State Department of Insurance or State Department of Health. See the Appendix for specific references to learn more about these laws and how to seek assistance, including the National Coalition for Cancer Survivorship’s publication entitled, What Cancer Survivors Need to Know About Health Insurance.

An organization that provides assistance with insurance matters and can serve as a liaison between patients and their insurer is the Patient Advocate Foundation. They have case managers, doctors, and lawyers on staff to help people resolve insurance issues (as well as job retention and/or debt matters related to their cancer diagnosis), with the goal of assuring patients’ access to care (see Appendix for contact information).