How to Fight Health Insurance Denials

My recent health insurance debacle, which I wrote about in a story published today, reminded me of The Rainmaker. The 1997 movie stars Matt Damon as an inexperienced lawyer who takes on a large insurer that has denied claims for treatment of a young man's leukemia. In one courtroom scene, lawyers for the insurer explain that coverage for a bone-marrow transplant was denied because it was considered experimental—the same wording that Aetna used in its original denial of my pregnancy ultrasound claim.

When I received the response to my appeal of the decision over the weekend, which upheld the original denial of coverage, I couldn't help but think of the letter from the insurance company in the movie. It read: "Dear Mrs. Black. On seven prior occasions this company has denied your claim in writing. We now deny it for the eighth and final time. You must be stupid stupid stupid. Sincerely, Evert Luftkin, Vice President, Claims Department." (My letter was plenty polite, but it still left me feeling extremely frustrated.)

How can a consumer protect themselves in this type of situation, when her doctor's office and health insurance company disagree on whether a procedure is considered standard or not? (In my case, my doctor's office says all pregnant moms should receive a certain type of 20-week ultrasound; my insurer says that level of scrutiny is unnecessary in healthy pregnancies and a less complex ultrasound would suffice.) I'm certainly not the only one to find herself in the situation; an online forum of expectant moms makes that clear.

The first step is to investigate by asking both your doctor's office and your insurer about what is covered and what is not. Aetna spokeswoman Wendy Morphew explains, "We are asking the patient to ask more of these questions. 'What tests are you proposing and why are you proposing them?'" Then, if you get an unexpected bill in mail, you can call the doctor's office and insurance company to ask why and potentially fight it. If you don't think the denial in coverage was fair, then you can file an appeal. If that's rejected, you can take your claim to the state insurance office.

I have taken all but the last of these steps, to no avail. Because my blood pressure rises each time I deal with this issue, my husband long ago urged me to declare defeat and pay the bill myself. I think it's probably time for me to do that—after I file one more appeal.

Have you dealt with this kind of challenge? If so, were you successful in resolving the issue?

For more, read Health Insurance Claim Denials: Fighting Back.