Cracking the Health Insurance Denials

It could be among your worst nightmares -- getting denied by your insurance company for a potentially life-changing or life-saving medical treatment. Health insurance companies are required by law to have an appeals process, but advocates say too few people take advantage of their right to appeal.

"It's not fair that I can't get the attention that I need, the medical care that I need," said Ellaine Janicki of West Haven, who suffers from fibromyalgia, an auto-immune disorder that causes her intense and ongoing pain.

Janicki says she was undergoing 30 physical therapy sessions a year. Her insurer, HealthNet, paid for the services until cutting her off last year. Janicki appealed the coverage denial, but lost. By letter, HealthNet told her such services are covered only "when rendered for an acute condition for a short period of time."

After exhausting her appeal options with her insurance company, Janicki then appealed to the state Department of Insurance, where outside reviewers upheld Health Net's initial denials.

"I'm on disability and my husband's semi-retired," said Janicki, frustrated by the process and the outcome. "What am I supposed to do?"

While the appeals system did not work for Janicki, it does work for others. According to insurance department records, just about five percent of people denied coverage ever filed an appeal with their insurance companies in 2007. Of those who did, state statistics show about 40 percent won those appeals. The numbers do not include self-funded plans.

People who exhaust their appeals with their insurer do have the option of appealing to the state Department of Insurance for an external review, or to their company if their plan is self-funded. According to state records from 2008, about 44 percent of people who filed a final appeal with the state either won or had the decision modified.

The Office of the Healthcare Advocate helps consumers navigate the appeals process, taking on about 2,000 cases a year.

Healthcare Advocate Kevin Lembo says his office had a 75 percent success rate last year, and an 85 percent success rate so far this year.

"Ninety-six percent of folks walk away from a denial by their insurance company, so our slogan this year is don't take no for an answer," said Lembo.

The Connecticut-based non-profit group Advocacy for Patients with Chronic Illness helps people file health insurance appeals nationwide. The organization takes on about 1000 cases every year, and helped Ellaine Janicki with her unsuccessful appeals, according to executive director Jennifer Jaff. Overall, the organization has about an 85 percent success rate, said Jaff, "which is why we know that insurance companies are denying way too often because we shouldn't be winning as many as we are."

To increase your chances of winning an appeal, advocates say you must understand what is covered under your plan. Also, understand why you were denied so you know what to include in your appeal. Before writing a letter, gather your medical records and other supporting documents to include in your appeal. Advocates also recommend taking notes whenever you talk to someone, and never appeal by phone.

"All you do is ask the insurance company to review what they're already reviewed," said Jaff.

While many remain frustrated with the appeals process, statistics show many patients win.

"If folks don't appeal, it's money out of their pocket," said Lembo. "If they appeal and win, it comes out of the insurance company's pocket which is where it was supposed to come from in the first place."

Besides processing final appeals, the state Department of Insurance also investigates consumer complaints about health insurance companies. In 2008, the department received nearly 1800 complaints and found 25 percent of them were justified, meaning insurers violated state statutes or regulations.

To file a complaint against your health insurance company, you can call the insurance department at 1-800-203-3447 or visit their website. You can also find information on how to file an denial of coverage appeal on the state's website. If you want to contact the Office of the Healthcare Advocate for assistance, you can call 1-866-466-4446 or visit their web page.

Contact Us