People often contact me, saying, “My appeal failed. What should I do?” I ask,”What was in the first appeal? What didn’t work?”

They invariably say, “I don’t know. My doctor wrote my appeal.”

First, it is not the doctor’s job to write our appeal. We need to take charge of the insurance piece, make their jobs as easy as possible, and leave them free to expend all of their energy and intelligence to administer our lifesaving treatments.

If your doctor is contracted with the insurance company, he is not ideally positioned to fight the insurance company.
If your doctor-of-choice is out of network (not contracted with the insurance company), he has no influence whatsoever with your insurance company.

You may ask, “How about if I get a lawyer to fight this for me?”

Good luck with that. Attorneys are not, for the most part, interested in fighting denial of care cases. There is no money in it. If you win your case, there will be no damages assessed, because you haven’t let them damage you yet. All you get is your life saved, all you get is your treatment.

There is no getting around it. You are the only person who has any traction with your insurance company. The contract is between Acme Insurance and YOU.

The fine print in your benefits booklet may not provide for the surgery/drug/treatment that you are seeking. They may even state quite clearly that they are not going to pay for it.

No matter. In all of the forty-four appeals that I have won, the insurer had stated that the treatment was not a covered benefit. But they paid.

How could this be? Because there is what I call the “Unwritten Contract” between you and your health insurer. On the face of it, none of the insurers in my forty-four cases would ever have had to pay a dime for any of these treatments. I believe that the reason that they do pay—after being severely intimidated by my written document—is the unwritten contract.

Nobody speaks of the unwritten contract, but insurance companies invoke it all the time—particularly in their promotional materials. Every time your insurer uses words meant to make you feel safe and cared-for, they portray themselves as keepers of this contract.

“You are in good hands with Acme Insurance.”
“We are the Rapid Response Resolution Team.”
“The name of our company is Neighborhood Health United.”

We are part of your neighborhood. We have health. We are united.

My appeals win because of this unspoken, unwritten, underlying agreement. What is the unwritten contract between you and your insurer?

Your part of the contract is to faithfully pay your premiums every month. The insurance company’s part of the agreement is, when you get sick, to make a good faith effort to provide appropriate treatment for you.

Your insurer pretends to operate according to this vision of health insurance. However, they have a thousand ways of getting out of their obligation—which is to pay for your treatment.

You are the one who will have to fight for what is fair, just, and right—regardless of what it says or does not say in your benefits booklet. And YOU are the one who is going to make your insurer uphold the unwritten contract, and do what is right.

Next Excerpt 2 “What an Appeal Is Not”
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