Obtaining the Medical Care You Deserve

What happens when your insurance company rejects the procedures you need? There are options available to you and ways to get your health needs met by following a few keys steps.

In the greatest time of need when emotions are high and uncertainty exists, you hope your insurance company will come through. And in a preponderance of circumstances, the doctors, care coordinators and insurance companies work diligently to get people better and take care of business. But sometimes it does not work out. Here are suggestions on how to get your needs met.

If you are experiencing a “small” issue, normally your agent and your doctor’s office can straighten it out. But if the situation is “large,” also known as very expensive treatment, you may experience a denial response. Fear can lead to anger, or for some, they just give up.

The key to obtaining the care you deserve is “to never give up,” says attorney Mark Hiepler of Hiepler & Hiepler in Oxnard, an expert in insurance complaints and recognized as one of the Top Ten Trial Lawyers in the nation. Mr. Hiepler recommends that you start with the following 5-point plan and, if necessary, escalate pressure if the intended results are not reached.

1. Never give up and understand the “squeaky wheel gets the grease.”
2. Write a four-paragraph letter that starts with who you are, your family circumstances, the issue at hand and the solution you are looking for. This humanizes the message.
3. Make sure your doctor is involved in the case to push it along.
4. Overnight and fax your appeal to the CEO, CFO or Medical Director of the insurance company (go to the “top” people).
5. Follow up the letter with phone calls. Mr. Hiepler stresses that you want to press for “accountability” and that you are looking for a resolution vs. a fight.

If this process does not gain satisfaction, the CA Department of Managed Care can be a good resource. “They have a 48-hour life threatening review process that can be beneficial in helping with patient rights,” says Hiepler.

The last resort is legal action, but it may be necessary in order to force the desired result. Hiepler says, “denial of treatment is usually accompanied by the claim that a procedure is medically unnecessary, experimental or they will not pay for the top doctors, all meaning that it is too expensive from their perspective.”

Though you are going up against a large company, “the fear of bad publicity through school fundraisers, for example, or national news can be extremely effective. The last thing an insurance company wants is bad press,” Mark Hiepler goes on to say. Mark would know from experience, as he won an $89 million dollar judgment against an insurance company for bad faith practices in withholding medical care–a judgment that helped open treatment to others.

These can be trying and emotional times. Let your voice be heard and get others involved if you can’t obtain the results you are looking for. Just don’t give up.