Check Health Insurance Appeal Process: Steps to Dispute Claims
The appeal process for health insurance is a task that is often difficult to handle. Many times, it goes unaddressed or remains unanswered for any number of reasons.
Therefore, every individual can appeal against the decision of the insurance company taken on their health insurance. The health insurance companies also have to recheck their decisions and have to provide a valid reason behind all of the refusal cases. However, at the time of seeking health insurance, there are some key things you should ensure.
This article will explain about health insurance appeal, types of appeals processes, mistakes to avoid and reasons related to insurance rejection.
Table of Contents
Ways of Health Insurance Appeals
There are two major ways to appeal for health insurance as follows:
Internal:
To appeal for health insurance it has to go through an internal appeal process first with the insurer. In all cases of any rejection on your health insurance claims, you must contact your insurance company and try to find out the reason for the rejection. They will give you a clear justification for declining your claim. You have to do this step before proceeding further.
External:
Sometimes internal appeals are not effective, and one can apply for an external health insurance appeal. In this process, an independent assessor (who has no relation with the insurance company) will review your case. This is the last process to seek a claim. If this process also does not work, then your health insurance appeal will be finally rejected.
Reasons for Appealing in Health Insurance
There are many reasons behind rejecting claims. At the time of appeal, it is essential to know many possible reasons behind the decline of claim. This will assist you to achieve more successful claims.
Reasons for Appeal for Health insurance:
- Referring to a special part or segment with respect to treatment or service.
- Cancellation of your health insurance policy coverage suddenly.
- Disagreement on the amount of bill or way of payment.
- Dispute against any practice that has not been mentioned in the policy.
How to Prepare for a Health Insurance Appeal?
If you want to have favourable results in a Health Insurance Appeal, you should take the following basic preparation steps-
Understand Your Policy:
The first one is evaluation of your policy. You must know the advantages and scopes of your health insurance policy so that you can access better results in case of an appeal.
Gather Documentation:
Some documents are also needed such as medical reports, doctor letters, activity reports etc. You should gather all these properly.
Take Help from Your Doctor or Healthcare Provider:
You can consult with your doctor or healthcare provider to have better results. They will help you to produce some evidence that may be considered in support of your appeal, which was always genuine. You can also produce a letter stating the medical condition and why the treatment is required for your health. To give it more weight, pure research articles from peer-reviewed journals or the guidelines of treatment on certain health conditions can be incorporated.
Keep Detailed Records:
Record in detail everything concerned with your appeal, in case something comes up. This is especially pertinent to avoid the many cases of lost information.
Review Deadlines:
There is no point in submitting an appeal that is past the deadline. Since all levels of the appeal process have different deadlines, you should never miss the deadline at any cost. You can also personally contact your health planner to know the exact days for each deadline.
How to File Internal and External Appeals?
The internal and external appeals do share some similarities and require the following fundamental steps to secure a result. They are as follows:
File for Internal Appeals
You need to prepare a letter to the insurance company, asking for a new appeal of the decision made. It needs your name, policy number, claim number, and an explanation of why you need to appeal the decision made by the insurance company. Always ensure that you fix all the enclosures that are likely to be useful in this case.
Follow-Up:
Follow up is very important for getting successful results. Generally, every company has unique time frames in which they inform you of your benefits. Consequently, the reconsideration usually takes 30 days. If there is any special reason that you wish to appeal, then state the reasons that qualify the appeal as urgent.
File for External Appeals
The only time that you can make an external appeal is if you fail to get a result from the internal appeal. You won't have to do much in order to complete it, but rather pick up a form from your insurance company, or even more so find one on their website. Next, get the form completed with the help of a third party and lodge an appeal along with all the documents to the external review organisation. It may take some time depending on the organisation.
Wait for the Decision: You can be required to wait up to 45-60 days to have your appeal reviewed. So, now it is in their hands as the last recourse how they will handle your case after you have filed an appeal.
Please note that you can always connect with an InsuranceDekho agent on +91-755 1196 989 or email us at support@insurancedekho.com with your queries. We will assist you in compiling your documents, connecting with your insurer, etc.
Please note: InsuranceDekho has no part to play in determining your claims, we can only help with documentation and assistance.
Common Mistakes to Avoid to Appeal for Health Insurance
- Failing to Understand Policy:: Most of the people have no idea about the policy they own. Mostly, they do not read all the benefits, terms and conditions, limitations on coverage etc. Although it is very important to understand what the policy offers.
- Missing Deadlines: Every insurance company has a different timeline, and everybody needs to abide by these timelines for appeal. If one fails to submit the appeal before the stipulated time, then he will be considered as not having pursued the appeal at all.
- Lack of Proper Documentation: When appealing, one has to make provisions for all the documents with regard to health insurance. Most times, people usually forget to add all the important documents that they wish to take with them. It is also good to double-check misplaced words in your name or address before appealing.
- Seeking Professional Help: This is the point where medical aid plays a very influential role in the health insurance appeal, especially in cases insisting for professional assistance. One can utilise the opportunity to interact with professionals in the form of patient advocacy or legal aid for much-needed help.
- Staying away from all these blunders will guarantee the best possible outcomes. In any event, it is always valuable to keep them in mind and try not to commit these typical mistakes.
Resources and Support for Health Insurance Appealing Process
There are some other resources and support which help in the Health Insurance appeal process. So, let's check-
- Patient Advocacy Groups: The correct assistance or proper resources that might be needed for health insurance appealing may be available at Patient Advocacy Foundations. It leads to appropriate steps that are needed in order to achieve successful results.
- State Insurance Departments: In case of any challenge, you may consult your state insurance department. They assist you to fill an external appeal and also inform you on your rights.
- Legal Assistance: It is crucial to get legal help for complex appeals. You can consult an attorney because they are aware of health insurance claims and can guide you through the appeal process.
- Healthcare Providers: When appealing for health insurance claims, always contact your doctor or any healthcare provider. They can help you in the process and can provide you with all the necessary paperwork and assistance.
FAQs
Ques 1. When can the applicant forward an appeal to the insurance company?
Ans. In case your claim gets rejected then you can obviously contest for it by writing an appeal to the insurance company. You have all the right to revisit your appeal and also to know the reasons behind why the appeal got rejected .
Ques 2. What to do if a mediclaim is rejected?
Ans. In case your mediclaim is declined, try to understand the reason for the rejection. Then appeal to the health insurance company to reconsider your claim or take professional advice.
Ques 3. How many times can health insurance be claimed?
Ans. Health insurance can be claimed as and when needed. This depends upon the terms and conditions, coverage limit, etc., all specified by your insurance company.
Ques 4. What is the time limit for insurance claim settlement in India?
Ans. IRDAI has decided the time limit of resolution to be within 30 days from the date of raising claim for any insurance claim settlement. Hence, most of the insurance companies try to settle the claims within ten days.
