September 20, 2002

Has your health-insurance plan refused to pay for a medical or surgical procedure, or a drug, recommended by your doctor?

Don’t despair, don’t give up and don’t take no for an answer, say the experts. Rejection is not the end of the line. According to the September 17 Wall Street Journal, ordinary consumers all over America are getting their health-plan officials to reverse their decisions and approve previously denied treatments 95 per cent of the time.

What’s the trick?

Appeal to your health-insurance company, write Journal reporters Peter Landers and Amy Docker Marcus. If the insurance company refused to pay for a procedure or a medication, write the company a letter of protest and enclose supporting documentation. A 1999 study of appeals in New Jersey, Pennsylvania, Arizona and Rhode Island showed that a single appeal worked in 52 per cent of cases.

What if your appeal is turned down?

Appeal to the company again, say Landers and Marcus. The second appeal works 44 per cent of the time.

But if the second try fails too, you’re still not at a dead end, because there’s an alternative route to success.

“Forty-two states have independent review boards, with the power to overrule insurors,” Landers and Marcus write. “Those who went on to state review boards won 45 per cent of the time.”

If you aggregate the results of all three appeals, the reporters say, you have a 95-per-cent probability of getting the health insuror to reverse its decision. You CAN get coverage for the medicines and procedures your doctor prescribes.

The reporters said the appeal process works best when applicants follow a few simple rules to “navigate the health-care bureaucracy.”

Rule No. 1: Don’t make a phone call, even when the insuror has an 800 number, the experts advise. Write a letter instead. Rhonda Orin, an attorney at Anderson Kill & Olick who specializes in battling insurance companies, advises patients who have been denied treatment to “write a letter immediately acknowledging receipt of the denial, and stating the grounds as you understand them. Attach medical records and don’t sound angry. Draft a reasoned argument, backed up by evidence, as to why the procedure is ‘medically necessary.’

“If you get a second no,” write Landers and Marcus, “appeal again. The company’s first letter may offer several reasons why it doesn’t want to give you coverage. Reappeal, focusing on that specific reason. Get a letter from your doctor–and even a second opinion from another doctor–showing why the procedure was a medical necessity. Look for medical articles on the Internet that show the procedure is a recognized treatment in the medical profession.”

Rejection of the second appeal is the point where most people give up, especially those who get a letter from the insurance company stating, “This is your final appeal.” But giving up now would be a mistake, write Landers and Marcus. They advise: “…if the dollars are big enough, it’s worth another step. Write one more letter, asking if there’s anyone else in your insurance company you should talk to.”

There’s a good reason for this final letter, Landers and Marcus say. You need it to show the state review board that you made an exhaustive good-faith effort to win approval from your insurance company. Thus, you are justified in seeking outside help from state regulators after your efforts fail.

“UTU members living in Illinois can get this kind of help from the Illinois Department of Insurance,” said UTU Illinois Legislative Director Joseph C. Szabo. “All they have to do is go onto our Web page at and then click the link to ‘State Agencies’ followed by ‘Illinois Department of Insurance.’ Any member having a dispute with a health-insurance company should turn to that site if they are unable to get approval after writing appeal letters as suggested in the Wall Street Journal article.”

According to the article, the U.S. Supreme Court recently ruled that state medical review boards have the final say in whether an insurance carrier must pay for a medical procedure.

“But most patients are unaware they even exist,” Landers and Marcus write. “By some estimates, only about 4,000 people use them each year.” The Journal says the review boards, which are made up of MDs specializing in the procedures under dispute, usually rule within 60 days–even faster if the treatment is shown to be needed on an emergency basis.

“The Web site will tell you what kinds of documents you need to prepare and where they should be sent for state review,” Szabo said. “The medical review board is a wonderful resource that few people know about–just as few people know how effective a letter and documentation submitted to the insurance company can be.

“I strongly urge an Illinois UTU member whose family has been turned down by a medical-insurance carrier to follow the appeal procedures set forth in the Wall Street Journal,” Szabo said. “And I urge just as strongly that members turn to the state review board’s link if an appeal to the insurance company fails.”