Q: My insurance company refused to pay my claim for an emergency treatment for my child’s stitches to a cut forehead. I had taken her to a 24-hour emergency care clinic near my home rather than to my pediatrician several miles farther away because there was heavy bleeding. I called the insurance company and argued, but was told I should have followed standard procedure and seen my pediatrician first. Should I appeal? If so, what’s my next step?
A: We strongly urge you to appeal. Because heavy bleeding is considered an emergency, your insurance company should have covered the stitches required to control it if your deductible was met. Appeal directly to the medical director of your health plan. That person typically understands that pediatricians generally do not do stitching in cases like these. To bolster your case, enlist the manager of your pediatrician’s office to write a letter to your insurance company explaining their policy. And then think about switching to a different insurance plan next year.
Need more help?
Decode the alphabet soup of insurance terms with this glossary at the National Association of Insurance Commissioners. http://www.naic.org/consumer_glossary.htm
Hire a professional claims specialist, who can help organize your claims paperwork, deal with the insurer, spot errors, collect extra documents from doctors, and help you file an appeal. Find one at www.claims.org. Expect to pay about $130 to $150 per hour.
If you have any questions about your policy, your rights and protections, or a potential agent or insurer, you can contact your State Insurance Department for information.