Health Insurance Claim Articles

Getting The Claim Decision In Writing

Sometimes, insurance companies will verbally convey a claim decision to a policyholder.  If this happens to you, it is imperative that you ask the carrier to memorialize its claim decision in writing.  Why is it important to have the carrier reduce its claim decision to writing?  Well, there are several different reasons, but here are a few examples. 

First, I have seen insurance companies retreat from a verbal claim denial when asked to put the denial in writing … in fact, I experienced this just a few days ago while assisting a health insurance policyholder.  Second, if the carrier has verbally approved your claim, you obviously want to lock that in before the carrier (perhaps at the supervisory level) attempts to wiggle out from underneath the approval.  Third, and conversely to the second point, if the carrier has denied your claim and you (and / or your representative) someday contest the denial, it will be better for you (and / or your representative) to have the decision in writing for a couple different reasons:  (1) Written word (as opposed to spoken word) is tougher to manipulate, and, in my experience, insurance companies will not hesitate to engage in after-the-fact manipulation if doing so is self-serving; (2) In Florida (at least), estoppel (or mend the hold) is alive and well in many courts; i.e., many courts will not allow an insurance company to bolster a claim denial with “bases” for claim denial not set forth in the carrier’s claim denial letter. 

In Florida, for example, statute requires the carrier to oblige your request for a written claim decision.  See, e.g., Fla. Stat. § 626.9541(1)(i)3.f (requiring an insurer to “promptly provide a reasonable explanation in writing to the insured of the basis in the insurance policy, in relation to the facts or applicable law, for denial of a claim or for the offer of a compromise settlement”).  You should not be adversarial in so requesting … a simple “Would you please put the claim decision in writing?” will do just fine.  If the carrier refuses to oblige your request for a written claim decision, let me know ... there are several things we can do about that.  

http://www.worldstemcellsummit.com/files/2009_report/4-9_2009.pdf

Health Insurance Claim Articles