Has your insurer refused to pay a claim?
Too often, individuals squander away their rights with incomplete and ineffective appeals. Appealing a claim is an art, not a science. YBA knows whether to appeal, when to appeal, how to appeal, and will submit the best appeal possible.
—Susan H. Loeb, JD, Your Benefits Advocate
Appeal of Medical Claim Denial
Insurers incorrectly pay or flatly deny coverage for three main reasons—clerical and coding errors, a lack of “medical necessity” or because the service is excluded under the terms of coverage, regardless of medical necessity.
Obviously, billing errors are the easiest to fix if you are willing to spend the time to get them corrected. But if you don’t have the time or inclination to handle this on your own, YBA can do it for you.
Denials based on no “medical necessity” are more difficult to handle on your own. If the insurance company determines your treatment is not “medically necessary,” it becomes the patient’s burden to prove otherwise. To prevail, you will need your doctor to make the case that the treatment or test is medically necessary for your condition. You also need to find out how the insurance company arrived at its decision because often the internal review process is inadequate. YBA will work with you and your doctor to support a case of medical necessity and challenge the insurance company’s denial.
A denial stating the service is not covered under your plan often comes as a shock, especially when it involves expensive medical treatment. Before undergoing treatment, YBA can review your plan and let you know what you should expect in the way of coverage. If the service needs pre-approval, YBA can pursue coverage on an expedited basis. On a post-service basis, YBA can review your plan to determine whether the denial was justified. If it wasn’t justified, YBA will vigorously pursue coverage on your behalf. Otherwise, YBA can help negotiate a settlement of the charges with the provider. See Success Stories.
Appeal of Long-Term Care Denial
Long-term care insurers refuse to pay benefits for a variety of reasons. The language of the plan is the guide for determining the merits of a denial and how to challenge it. For example, older policies often narrowly define eligible home health care providers. If your caregiver does not meet the definition, the claim will be denied, but there may be grounds for appeal. Another common reason for denying benefits is a conclusion that the covered individual has failed to establish that (s)he cannot perform two or more “activities of daily living,” as defined under the plan. To successfully overturn a denial, your medical providers and caregivers must develop a detailed “plan of care” that supports the need for the services provided under the plan. When it seems like there is no way around the denial, YBA constructed creative arguments to secure benefits. See Success Stories.
Appeal of Denial of Long-Term Disability Benefits (other than Social Security Disability Benefits)
It can be difficult for disability claimants to secure and maintain benefits because their disability often prevents them from being an effective advocate for their rights. Insurers of individual or employer-sponsored long-term disability plans carefully scrutinize both the initial application for benefits as well as monitor on-going disability status. Insurers will deny benefits if the disability is a pre-existing condition as defined by the plan; if the claimant is not under the regular care of a doctor; or if it is believed that the disability is not severe enough to prevent the claimant from performing the essential functions of their job, or from working in general. YBA knows how to successfully challenge a decision to deny or cut off benefits.
Appeal of Denial of Life Insurance Benefits
The language of the life insurance policy dictates the payment of benefits. YBA has helped clients reinstate their policy after a lapse in premiums and secured benefits for a husband whose wife’s coverage had slipped through the cracks when the employer changed carriers. See Success Stories.