Health Insurance Doesn't Always Protect You From Big Bills

The New York Times has a post today on people who have health insurance, but are underinsured, defined as paying more than 10% of income towards medical bills.  One of the reasons people who are insured still have big medical bills is that the insurance company denies medical claims that they should pay.  They deny claims for many reasons, including that the requested treatment is not medically necessary, or is experimental, or the requested treatment is out-of-network and the insurer claims equivalent treatment is available in-network, even though your doctor disagrees.   This can occur with both private insurance, and insurance through an employer that is governed by ERISA

If an insurer does deny on a claim on these basis, you do have remedies that can keep you out of the ranks of the underinsured.:

• You can file an appeal with the plan.  This is a crucial step.  You cannot pursue any of your other remedies until you file the appeal with the plan.  Also, it may be your only chance to submit information in support of the appeal.  Having an  experienced Connecticut ERISA lawyer to handle the administrative appeal can help to make sure you have all the information in the file to succeed at the later appeal levels.  
• For appeals of denied health insurance claims in Connecticut, you can file an appeal with the Connecticut Department of Insurance. .  Here is a link to a guide to the process.  The Affordable Care Act requires states to establish procedures for appeal of denial health insurance claims, so there should be a similar process in your state if you are not a Connecticut resident.  
• If these don't succeed, you have the option of pursuing your claim in court: in federal court for ERISA claims arising from plans established by your employer; or state court if you purchased the plan directly.  Whether you have a good claim in court depends largely how complete your prior appeals were, so be careful with the appeals!

Insurers do not always pay the claims they should pay under the policy.  By effectively appealing the decision, you can increase the chance you will avoid the big bills that will make you underinsured.  An experienced employee benefits attorney in Connecticut or your state can be a big help in making this happen.