Life with MS

Appealing Insurer Decisions

For most people with private insurance, if you disagree with your health insurance plan’s refusal to pay for care, the plan will have to review its decision. And if you still are not satisfied, you have the right to appeal that decision to an independent reviewer who is outside of the health plan.

Research shows that consumers who do appeal outside of their insurance companies win their cases about 45 percent of the time.

The Kinds of Decisions You Can Appeal

You can appeal a plan’s decision not to pay for a benefit, or to reduce or end a covered service, when the
plan says any of the following:
  1. the care is not medically necessary or appropriate,
  2. you are not eligible for the health plan or benefit,
  3. you have a pre-existing condition,
  4. or the care is experimental or investigational.

If the plan has told you any of these things and you disagree, you can appeal.

The Appeal Process

First, ask for an internal review. You should receive a notice from your plan with instructions about how to request a review and the deadline for doing so. Other people in the health plan who were not involved in the plan’s original decision will review the case. They must consult with appropriate medical experts.

You have a right to get the details of why the plan refused to pay for your care. You can review the plan’s file about your case, get the medical evidence the plan used, and get the plan’s guidelines about when it does and doesn’t pay for the type of care you requested. The plan cannot charge you for this information.

You have a right to present testimony and more evidence for the plan to consider. You can respond to any evidence the plan uses. For example, you might want to submit letters from your doctors and information from medical journals about why a benefit is appropriate.

You can ask a consumer assistance program or another representative of your choosing to help you. If you want, you can ask the plan to continue paying for your treatment until the appeal has been decided.

Your Right to Appeal

You can get help with your appeal from a consumer assistance program. Many states have established consumer assistance programs to help consumers with appeals and to help them understand their health insurance rights. Notices from your insurer should give you contact information for the consumer assistance program in your state. You can also ask your state insurance department if there is a consumer assistance program, or you might be able to find a knowledgeable advocate to help you with your appeal by contacting a legal services program or your state bar association.