If you or a member of your family are suffering from an eating disorder, your insurer may balk at covering treatment by claiming it's "not medically necessary" or that coverage is limited by plan terms.
Knowledge is power when dealing with insurance companies. Their opinion and interpretation of your plan is not the last word. Here are some tips to help you prevail:
- Get a complete copy of your policy from your employer or the insurance company and read it carefully before going into treatment.
- If your insurance is through your employer, ERISA is meant to protect you. ERISA is a federal law that regulates health benefits provided through an employer. ERISA requires health plans to comply with procedures for denying claims and appeals. Find out more here.
- Read and re-read the medical necessity definition and guidelines your insurance company or their administrator is using. You may need to request these documents in writing form your insurer.
- Understand your appeal rights and appeal deadlines. These will be provided in your policy and attached to denial letters. When in doubt, the deadlines in the policy control.
- What makes the treatment medically necessary as defined in their guidelines? Put your strongest reasoning in your appeal, along with treatment records and a letter from at least one medical provider confirming that it is medically necessary.
- Put your appeal in writing and submit it on time with a method of delivery confirmation.
- Submit a post-service claim if the denial was pre-service or during treatment.
UP thanks and acknowledges Elizabeth Green and Cari Schwartz of Kantor & Kantor LLP for their contributions to this publication. Ms. Green's practice focuses on ERISA health cases and Ms. Schwartz's practice focuses on bad faith health cases.