Learn how to spot and avoid impostors at our free, two-part webinar Feb. 18 and 20. Register today!
by Candy Sagon, From the AARP Bulletin Print Edition, September 1, 2010
Fighting back when your health insurance company denies a claim just got a little easier, thanks to federal rules recently issued under the health care overhaul law.
The new regulations expand consumers’ rights to appeal denials, including the right to an independent, external review board. Consumers can also use the appeals process when their coverage is canceled.
Previously, rules regarding a patient’s right to appeal varied by insurer and state. The change creates consistency in the appeals process and—for the first time—extends the external review guarantee to employees of companies that offer their own health plans without contracting with an insurance provider.
The regulations will apply to new health insurance plans starting Sept. 23.
“Until the [health care law] reform, only a select number of states honored external review,” says Erin Moaratty, a spokeswoman with the nonprofit Patient Advocate Foundation (PAF), which helps patients navigate the appeals process. “Now every state is required to have a process for external appeals.”
The Hampton, Va., foundation helped Rona Dondzilo, 60, of Spokane, Wash., get an external review after she had been denied coverage for treatment of endometrial cancer. “The insurance company said it was a preexisting condition because I had been spotting before I was diagnosed,” Dondzilo explained.
She appealed using the insurance company’s internal process, then turned to PAF to help her get an external review. She eventually won.
To date, external review boards have reversed about 45 percent of appealed denials, according to the Kaiser Family Foundation.
In order to successfully overturn a denial, Moaratty stresses, consumers must keep careful track of paperwork and phone calls. The three most important tips PAF tells its clients:
Keep records. In a notebook or binder, carefully write down the date and time of each call to your insurer, whom you talked to and what you discussed.
Watch deadlines. Make sure you meet the insurance company’s deadlines for filing an appeal. The deadlines are spelled out in the insurance contract. If you miss a deadline, it may be impossible to file an appeal.
Follow up. Don’t assume that something will be done just because you made a phone call or sent a fax. And if you mail information to the company, make sure you send it certified so that you get a receipt showing it was received.
Remaining determined is also key, says Dondzilo.
“People get a denial and think they won’t win, but they need to take it as far as they can,” she says. “It’s their right to keep pursuing an appeal.”
Candy Sagon writes about health and nutrition for the Bulletin.
Please leave your comment below.
You must be logged in to leave a comment.
Members can take a free confidential hearing test by phone.
Members get Staying Sharp for FREE – brain-boosting recipes, activities, games and more.
Members save 15% all day, every day at participating locations.
AARP members receive exclusive member benefits & affect social change.
You are leaving AARP.org and going to the website of our trusted provider. The provider’s terms, conditions and policies apply. Please return to AARP.org to learn more about other benefits.
Your email address is now confirmed.
Manage your email preferences and tell us which topics interest you so that we can prioritize the information you receive.
Explore all that AARP has to offer.
In the next 24 hours, you will receive an email to confirm your subscription to receive emails
related to AARP volunteering. Once you confirm that subscription, you will regularly
receive communications related to AARP volunteering. In the meantime, please feel free
to search for ways to make a difference in your community at