Ten Steps to Protect the Legal Rights of Patients*

#1. Read your health insurance policy carefully.

If you have health insurance coverage through a private employer, obtain a copy of both your Health Insurance Summary and a copy of the Master Insurance Policy. Your employer is required to provide you with a Summary of your health insurance plan coverage. Your employer’s human resources department will have typically provided you with a Summary policy at the time you signed up for the coverage. However, the Summary may not include a detailed description of all of the covered benefits and exclusions. Employers are often provided with a Master Policy that goes into great detail regarding what is and what is not covered. Under Federal law, your human resources department and/or the insurer should provide you with a copy of the Master Policy.It is essential that, if possible, you thoroughly review both the summary and a copy of the Master Policy. If the two policies are not the same, you may be able to use this in an appeal, if one is necessary.

In reading the policy, look for references to the “plan administrator.” This information is typically at the beginning of the policy and /or at the end of the policy. The plan administrator may be an insurance company or it may be your employer. This information is important because the plan administrator typically has the right to make the final decision about your coverage.

#2. Determine whether the treatment prescribed by your physician is covered by your policy.

Check to see if there is an “exclusion clause” and/or an “experimental/ investigational” clause in the policy. This will give you some indication of whether the treatment, for which you are seeking approval, is excluded from coverage by your health insurance carrier. Also, look at the definition of what treatments are considered “medically necessary.” Some treatments may not be specifically covered by your health insurance policy. If that appears to be the case and you need the treatment, see a knowledgeable lawyer.

#3. Know your insurance policy appeal process.

After you have been denied coverage for the requested treatment, make sure that you meet all the deadlines set by your insurance carrier for appeals. In the first letter from the insurer that denies coverage, check to see if the company has given you a deadline by which an appeal or response from you is to be received by the insurance company. If so, make sure you respond by that deadline. All communications should be in writing and sent by certified mail, return receipt requested.

Appeal procedures should be included in both the summary and master policy. If it is a lengthy policy, the appeal procedures may be hard to find. They are typically near the end of the policy. Read your denial letter carefully. If it does not include a deadline for an appeal and a description of each stage of the appeal procedure, write to your insurer and request that they immediately send you this information in writing. Sometimes a deadline for an appeal may exist without your knowledge. Stay on top of this and meet every deadline.

Remember, always communicate in writing!

#4. Obtain legal advice from an attorney who is knowledgeable on health insurance issues.

It is essential that you have legal advice if you have been denied coverage for treatment or services prescribed by your treating physician. If your life or health is in jeopardy, consult a knowledgeable professional as soon as possible. While it is unfortunate, the reality is that a letter from an attorney is often taken more seriously than a letter from the person who is insured. Such a letter can often speed up a reversal of a denial of coverage.

If you cannot afford a private attorney, there are pro bono attorneys through the local Bar Association who may be available to give you free advice. Just make sure the person from whom you seek advice is knowledgeable about health insurance. Be skeptical of any “professional” who has not worked in this area before. In addition, do not wait until you have exhausted all of your appeals before consulting an attorney. Often there is little that can be done after the appeals process has been exhausted.

#5. Plead your case in person to your insurance carrier.

If you can make a personal appeal to a Grievance Committee, it is often more effective than a written appeal. Find out who sits on the Grievance Committee. Ask if you may bring your doctor with you and your lawyer. Again, having a knowledgeable lawyer with you can only help your case. It demonstrates that you are serious about protecting your rights and may help to speed up the appeals process.

#6. Personalize your written case with your insurance company.

If you are not allowed to appear before a Grievance Committee, submit your photograph, along with photographs of your family and friends. You should also include letters from your family, friends and clergy. Submit anything that will help to personalize your case. Remember that you are fighting for your life and/or health. Make sure that each person reading your case realizes the personal impact and consequences of their individual and collective decisions!

#7. Obtain copies of your medical records.

Make sure that you have legible copies of all your medical records related to your current medical treatment. Also have any correspondence between your physician and your health insurance carrier. Make sure that your physician continues to send you any correspondence between him/her and your insurance carrier. Your physician may charge you for copies of your medical records, but you are legally entitled to receive all of your medical records.

#8. Document everything!

Document your telephone calls. Each time you speak with a representative of your health insurance company, keep detailed records including the date and time of the call, the person’s name, their title, their telephone number, their supervisor’s name and what was discussed. If the representative made any promises or assurances, be sure you have an accurate record of exactly what was said and send a letter confirming the promises or assurances. If someone else is calling on your behalf, make sure they also keep detailed notes.

#9. Ask your physician to advocate for your treatment.

Obtain an affidavit or a declaration from your treating physician (and any specialists who have been called in for consultation and/or treatment) that specifically describes your illness and what is required to treat your illness. This statement should also include a brief medical history, your prognosis with and without the requested treatment, and a copy of the treatment protocol, if applicable. Your physician(s) should include, with the sworn statement, current copies of whatever medical literature is available on your illness and the proposed treatment. If possible, all of this information should be sent to your insurance carrier with your first written appeal. If a knowledgeable lawyer is helping you, make sure that you sign a written release of your physician/patient privilege so that the lawyer or his or her legal staff can discuss your treatment with your physician(s).

#10. Be prepared to fight!

Your health may prevent you from being the best advocate for your own treatment. Enlist the help of a friend or family member, if you are not prepared mentally and/or physically to fight for your appeal. Don’t worry about being “nice” or pleasing other people. You may have to be rude, persistent and/or demanding. A knowledgeable legal professional can best assist you with cutting through the red tape and delays that you may face during an appeal. A lawyer will be able to file your case in court, if that appears to be the only recourse left to you following your appeals with the insurance company.

*This information is not a substitute for knowledgeable professional legal advice based on the unique facts of your case. This information does not purport to be, nor is it, legal advice.