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Insurance Not Paying?

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I am going to use the State of Texas as an example. Each State is a little different and you should check with the Insurance Agency or Board in the State it pertains to, and find out what your rights and responsibilities are.

If you are having a problem with your insurance paying what you thought was covered, you should review your insurance policy or benefit plan terms and agreements and/or contract to make sure you were covered. Read the Consumer Bill of Rights. Insurance companies must include the "Consumer Bill of Rights". It explains your rights and responsibilities. For a copy, call your insurance company or the TDI Publications Order Line at 1-800-599-SHOP (7467). In Austin, call 305-7211. Keep copies of all correspondence between you and the insurance company. Write down information about your telephone and in-person contacts, including the date, the name and title of the person you spoke with, and what was said. Also, keep a record of your time and expenses. Ask the company for the specific language in the policy that is in question. Find out if the disagreement is because you and the insurance company interpret your policy differently. You should be aware of any changes that may have affected your policy, and you can find out from your insurance agent or representative. Review your policy or benefit plan and pay attention to restrictions, exclusions, policy limits, lifetime coverage maximums, agreements to pay only what the carrier feels is reasonable standard and customary, and policy definitions. Determine what your policy or benefit plan covers and what it does not cover.

In most cases limited benefit policies do not provide the benefits or services needed to meet most health care expenses. Find out if prior "Pre certification" was obtain. It may be required to have pre certification for hospital admissions or provider referrals. You also will need to know if it’s your responsibility to notify the insurance company or HMO after being admitted to the hospital in an emergency?

If your policy is with a preferred provider plan, you should be aware of, and understand the consequences of going to an out-of-network provider. Determine if your policy allows the health care provider to bill you for charges not paid by your health care plan. Determine if the billing is correct and that the services and/or goods were rendered at the price that was agreed to.

Most insurance companies operating in Texas are required to have toll-free telephone lines for customer assistance. The toll-free number should be listed on your policy, or you can get the number by calling TDI's at Consumer Help Line at 1-800-252-3439. If you are going to call, have your questions and policy number available before you call the company.

If you have a dispute with your agent or company, I would put it in writing (certified- return receipt requested). This encourages a written response. State your complaint and how you expect the company to handle it. Include with the complaint copies (not originals) of letters, notes, invoices, canceled checks, or advertising material that support your complaint. A dispute process is used to resolve claims and disputes.

You may want to ask your physician to provide your insurance company with details about your treatment, medical condition, and prognosis. If you suspect a provider is over charging, ask the insurance company to audit the bill and verify whether the provider used the proper billing procedure. If you still owe a large balance, your provider may submit the bill to the local medical society peer review committee to review the charges. If your health insurer or HMO refuses to pay for a treatment because the insurer or HMO determined that the treatment is not medically necessary or appropriate, you can request binding review by an Independent Review Organization (IRO). You may request review by an IRO only on claims denied on or after September 1, 1997. For more information about the IRO process, call TDI's: TDI IRO information Line 1-888-TDI-2IRO (834-2476) In Austin, call 322-3400.

Texas law requires insurance companies and HMOs to pay first-party claims promptly. A first-party claim is one filed by you against your insurance company or HMO. Prompt-payment does not apply to liability insurance claims against another person's insurance company. It also does not apply to claims involving self-funded plans; workers compensation; mortgage guaranty or title insurance; fidelity, surety, or guaranty bonds; or marine insurance (other than inland marine). Next Page

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