Insurance Not Paying?
I am going to use the State of Texas as an example.
Each State is a little different and you should check with the
or Board in the State it pertains to, and find out what your rights and
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 its your responsibility to notify the insurance company
or HMO after being admitted to the hospital in an
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
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).
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