Disputes Over Health Plans & Consumers' Legal Rights
The language of health insurance plans can be confusing, and complex disputes sometimes arise over its interpretation. Sometimes an insurer may send an incorrect bill to a consumer, or it may deny coverage when a consumer believes that the plan covers a visit or treatment. If you are considering starting a dispute with your health insurance provider, you should be familiar with the terms of your policy and the process for pursuing a dispute.
For example, you should know your copayments and deductibles under the plan. A copayment is an amount paid by the consumer for each visit to a doctor or hospital or for each surgery or treatment. (It is usually a very small amount for visits to a doctor’s office, but it can be higher for hospital care.) In other words, it forms a small percentage of the overall bill, of which the insurer pays the rest. A deductible is the threshold at which the insurer starts providing coverage. You pay all of the costs below the deductible, which may be a few hundred dollars. The deductible applies on an annual basis rather than a per-visit basis. If you have exhausted the deductible earlier in the year, you may need to pay only the copayment for further medical care. This can give consumers an incentive to get as much treatment as possible within the same year before the deductible returns to zero.
Determining Whether to Pursue a Dispute
You can get a document from your employer called Evidence of Coverage. This provides a more thorough description of your plan than the Summary Plan Description. (People who are self-employed or who otherwise do not get health insurance through an employer can ask their insurer for the Evidence of Coverage document.) This will help you first decide whether you should pursue a complaint. Perhaps you were unaware of certain exclusions or requirements in your policy, which prevent a certain cost from being covered. If reading the document confirms your understanding of the policy, it will help support your position in the dispute. You can identify the specific part of the policy that the insurer misapplied.
It may be prudent to investigate the Evidence of Coverage document soon after signing up for the plan. In some situations, this may affect when and how you plan your medical care so that you can maximize the coverage.
How to Pursue a Dispute
You may be able to resolve a simple error by contacting customer service. If you were billed the wrong amount, this may be a typo that can be easily corrected. When a dispute is more complex, the customer service agent probably cannot resolve it on their own. You may need to talk to a supervisor or submit more documents to support your position. You should ask the insurer for a formal written notice of its decision to deny coverage or refuse to authorize services, which will come with an explanation of its reasoning.
Next, you can pursue your dispute through the internal review process of the health plan. In your appeal, you will need to follow the rules and procedures provided by the insurer in asking it to change its decision. You should review the Evidence of Coverage, which will provide the paperwork that you must submit and the time in which you must submit it. The insurer then will have a certain period, also provided by the Evidence of Coverage, in which to respond to your request.
If you receive an adverse decision on your appeal, you may be able to seek review of that decision through a process such as arbitration. This involves asking a neutral third party (the arbitrator) to review the dispute and make a decision. Arbitration may be binding, but it cannot be binding if the policy terms make it mandatory. If arbitration is binding, you cannot appeal the arbitrator’s decision. Even if arbitration is not binding, you may want to think twice before expending the additional resources on taking a dispute further into the legal process unless a huge amount of money is involved.
