If you have ever purchased a private insurance plan through a big provider, you may have noticed the coverage was not the same, even though it was supposed to be. Why is that?
The quick and dirty answer; you're just one person. If they deny you, they have nothing to lose.
In my experience, a private policy claim will most likely be denied if the claim is not routine, even if it is covered. They do this because they don’t have anything to lose. If you don’t appeal or “fight” them, they win. So in essence, it’s good business. However, if you are in a big group plan, they will do exactly what is covered. Big groups will hold the insurance companies accountable. It’s good business to keep the big customers happy.
If you are struggling with a private insurance claim you know is supposed to be covered, don’t give up just because it was denied. You can appeal it. If that doesn’t work, you may want to talk to a lawyer. Paying a lawyer may be cheaper than paying for your doctor bills. It was in my case.
My son had to have a surgery that would definitely be covered, but I had a private insurance policy, and they denied my coverage. The surgery was going to cost about a half a million dollars, way more than I could afford. If my son did not have the surgery, it would affect him the rest of his life. He had to have the surgery within the year or his condition would be irreversible. At first, it felt like there was nothing I could do, but as I began to research, I found there was a few things I could try.
I immediately began the appeal process. The insurance company I was with made me take my son to a different doctor to get a second opinion. This was going to take a while because it takes somewhere between 30 and 90 day just to get the medical records transferred. I cut that by two weeks just by getting them myself and hand delivering the records. Once their doctors came to the same conclusion, they still denied my claim. I reached out to a lawyer who was extremely excited to take the case. I’m not sure what he did, but the insurance covered it and then some. I didn’t even have to go to court.
If I had a group policy with a big company, I would have been covered and not had to fight the insurance company. For me and my son it was worth it not to just give up. Sometimes it pays to put forth the effort.
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