June 12, 2007

Housebreaking Your Health Insurance

Are you having trouble with your health insurance? Are they stalling on paying a bill? Denying a claim? Not telling you what the heck is going on?? Well you can and should take action to eliminate some of the mystery and move forward, and possibly win fight against the health insurance company.

Thanks to my unpleasant ordeals with BCBS of NJ, I have compiled some handy resources and tips to get you started. Good luck and I welcome any other tips that you think should be here. Please email them to me at biella(at)gmail(dot)com

Can’t get a straight answer when dealing with health insurance representatives on the phone? Are different representatives providing different and contradictory information? Does talking to the representatives leave you with a pounding headache? Then the following may be helpful:

1. Ideally you should tape record all conversations. If this is not possible, get the name or employee number of the person you are talking to and write down what they told you along with the time and date. If they have agreed to something, make sure they send it to you in writing. This sort of documentation may come in handy later when you are trying to contest or prove something.

Is your insurance company flip flopping on a claim? For example telling you that the claim is still being “reviewed” but sending you statements that indicate it has not been paid and never will be? What action can you take to inch things forward? The following may help:

1. Most states have a Department of Banking and Insurance and they are there to help you. Many (perhaps all) provide a service for filing a complaint against your health insurance company and other insurance and banking companies too.

When I used the service in NJ , I got assigned an investigator and their service was prompt and helpful. It was my experience that even though they were not able to resolve my issue, the insurance company started to make firm decision on many claims and this alone has been helpful. Before this, it was impossible to get a clear answer from them as to the state of all sorts of claims.

They said “NO,” & you think they should say “YES, YES, YES, YES!!!!” In other words, appealing a denial:

1. This site has some great information on how to avoid a denial and what you can do to fight one.

2. Included on their site is the Health Insurance Laws and Benefits Tool which will provide specific information about your rights in different states. For example, you will want to know if there is an external or independent grievance system to appeal your plan’s decisions. In the case of NJ, which is the state I am fighting, the tool provided the following helpful information:

Does New Jersey require an external or independent grievance system to appeal your health plan’s unfavorable decisions?

Yes, for all health plans.

On what grounds can you file your external grievance?
Investigational treatment appeal, medical necessity.

What is the status of the external grievance panel’s decision?

External grievance systems allow you to take a dispute with your health plan to a doctor or review board unaffiliated with your health plan. Thus, both you and your health plan receive an impartial ruling on its decision to deny coverage of services or treatment. Additionally, you can file a complaint against your health insurer with your state’s department of insurance.

Additional Helpful Information and Resources

1. The message boards on lawyers.com are a great place to hit for information. I have found folks there helpful.
2. You many want to blog about your experience as you may get an unexpected response directly from your insurance company. I think there are pro’s and cons to blogging about your experience but it does provide a public face to your ordeal and allows you to chronicle exactly what has transpired.
3. If your cases is particularly shocking, do not hesitate to hit the local media.
4. If your claim has been denied by an external review panel, you may not have much luck suing but if there is no external review panel, you can and should also try Small Claims Court or other legal action. Further, even if your claim was denied by an external review board, you may have other options for suing, for example, due to their bad faith handling of a claim. And on that note, here is a great legal resource covering the topic.


  1. Well, I’m happy I live in a country where I don’t have to care about such things…

    Comment by JanC — June 12, 2007 @ 5:04 pm

  2. I am sad that I am leaving such a country….

    Comment by Biella — June 12, 2007 @ 5:08 pm

  3. I also feel lucky for living in France (until system changes).

    Anyway, a question arises about legal differences : in France it is not possible to produce proofs in courts if you obtained them in a ‘treacherous’ way.
    That means that if you were to produce a taped conversation without your correspondent knowing he/she’s being recorded, that proof will be discarded. However, email being per se recorded, it is not ‘treacherous’ to use it as a proof as long as you can prove it not forged…).
    In practice you just have to tell the company’s employee that the conversation is being recorded (and you’ll get pretty good answers for your enquieries I bet).

    Does your legal system enforce restrictions of this kind ?

    Comment by Feth — June 13, 2007 @ 12:13 am

  4. Oh my goodness, Biella. I’m horrified at what you had to go through and the thought that this isn’t just some unlikely scenario but that US health insurance indeed is such a disaster for so many people.

    Like the other commenters, I live in a country where we are pampered with grade A public healthcare, and though lots of people complain about it being slow and expensive (through taxes, that is), it is still so much better than what you’re stuck with.

    Good luck with it all.

    Comment by Andreas — June 13, 2007 @ 8:23 am

  5. I, too, have been fighting with BC/BS of Florida, trying to get several claims paid from last year and this year. They keep telling me that they have never received the claims,but I have been shown by the doctor’s bookkeepers of confirmation of claims being turned in electronly,several times. I didn’t know what recourse I have against BC/BS. I have filed complaints of dissatisfaction, but no answers. BC/BS also is telling me after 1 year, they don’t have to pay any claims , if they are turned in later????? What am I to do.?????

    Comment by Janet Reeves — September 7, 2007 @ 10:28 am

  6. I have similar painful experiences as you with BCBS of NJ. That company is famous for its poor IT system. Data of Physicians and patients were skewed up by databases and applications. Surprise, the poor IT system is a money-making machine, helping the business to deny payment.

    Have you file complaint to New Jersey Department of Insurance?

    Comment by Rechael — January 16, 2008 @ 9:38 pm

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