Why an Internal Appeal is a Really Big Deal
If your insurance company denies your claim for coverage, this denial could mean you don’t get the medicine or procedure you need, or you have to go into your own pocket to pay for costly medical treatment that you can’t afford (medical bills are the number one reason families file for bankruptcy). Some people don’t know there is anything they can do about a denial, and they simply give up, either paying for medical care on credit or going without. Others who read their policy and letters from the insurer carefully do realize there are ways to fight a denial, but even then, they don’t always go about it correctly.
After trying to resolve an insurance dispute over the phone, email and written letters, the first step to a formal resolution is usually filing an appeal or request for review through the insurance company’s internal appeal process. Don’t make the mistake of thinking this is just some hoop the insurance company makes you jump through on your way to eventually resolving the matter. The insurer’s internal review process is actually a critical stage in the appeals process, and how you handle it can have huge repercussions down the line. Let’s take a look at why the internal review stage of your appeal is a really big deal.
ERISA Probably Governs Your Health Plan
Employer-sponsored employee benefit plans, including health plans, are governed and regulated by a federal law called the Employment Retirement Income Security Act of 1974, more commonly just known as ERISA. One of ERISA’s rules is that every plan administrator provide an internal appeal process that the policyholder can use if their claim for coverage is denied. Not only must insurance carriers have this procedure available, but it is a mandatory step for policyholders to go through. Under ERISA, you cannot take an insurance company to court unless you have first exhausted all available “administrative remedies,” which means using the insurer’s internal appeal process.
Once you’ve exhausted your administrative remedies, if you haven’t resolved your issue with the insurer, you could possibly sue them in court. A lot of factors go into deciding whether to take your case to court or not; this is a discussion to have with an experienced insurance lawyer. You can find a quality law firm that offers a free initial consultation to evaluate your claim. If you do decide to go to court, your lawyer will likely take your case on contingency, meaning you don’t owe the attorney any legal fees unless and until they recover money damages on your behalf.
The Internal Appeal Develops the Record for Trial
Say you decide to go to court. Here’s why that internal appeal at the insurance company was so vital. Because of ERISA, the evidence you are allowed to put before the judge can be limited to the evidence you presented during that internal appeal. If you did not put your best case forward at the internal review level, you go into court with the cards stacked against you. Instead of waiting until after the internal appeal to call al lawyer, have one represent you at that stage. An experienced insurance trial lawyer will know how to develop the record so that your whole case can be brought before a judge. Also, having legal representation just might help you resolve the matter at the administrative stage so that litigation is never even necessary.
