Previous Excerpt 4 “An Appeal Is a Bluff”

Your insurance company has always “taken care of everything.” They have paid for your routine care, your knee replacement, your blood pressure medication with no problems whatsoever. You anticipate a lifetime of worry-free healthcare—no matter what happens.

Then, all of a sudden—you need something that Acme Insurance does not want to pay for. They are just as polite and solicitous as always, and they politely say, “No.”

When the insurance company won’t pay, people call for help. Who do they call?

  • The insurance company
  • The Insurance Commissioner
  • A lawyer

Call the insurance company?

The insurance company is your friend, aren’t they? The name of the insurance inspires trust: “Neighborhood Health,” “Health Choice United,” “My Cross and My Shield.”

People come to think of their health insurers as quasi-social-service-agencies, standing ready to help them. They think of the insurance company as an entity that exercises logic and good ethical judgment at all times.

Until they need something that the insurer doesn’t want to pay for.

Before you pick up the phone in a panic, trying to straighten out this denial that is surely a mistake … know that your insurer is a business. Period. A business won’t come over and keep your feet warm at night. A business doesn’t care about your quality of life.

And a business cannot be expected to act in an ethical manner, unless forced by rules and regulations to keep to the straight and narrow.

The mission and purpose of a business is to control operating expenses, and to maximize net profit. Your health insurer is a business. It is their job not to pay.

In this day and age, most people are not writers. Insurance companies receive relatively few letters from patients, and millions of phone calls. Insurance companies have mastered the art of getting rid of you by phone.

Think about it. Acme Insurance has no intention of paying for your surgery/ treatment/medication. They don’t want to talk to you.

Whether the maddening phone experience with insurance companies is by design, incompetence, or a combination of both, I do not know. Suffice it to say that you aren’t going to get anywhere by talking to Acme Insurance on the phone.

The only phone number that is given to you to access the insurance company is the number of customer service (sometimes called “Customer Care,” to make you think that they care). Acme Insurance is the castle. You are storming the castle, and customer service is the first line of defense.

Customer service representatives do not have any inside information. They are not decision-makers, and they have no access to decision-makers. Their job is to be reasonably polite, get you off the phone, and protect decision-makers from you at all costs.

Last year I was writing a grievance letter for a very nice lady in Florida. She was trying to make the insurer pay for her husband’s lifesaving treatment after the fact. Camille had kept a list of all of the customer service, case manager, rapid responders, and other assorted bean counters that she had talked to at “Friendly Neighborhood Insurance.” Remember, talking to all of these people had not accomplished anything.

In trying to get this claim resolved, she had talked to forty-three people at the insurance company. They all had different answers to the same questions. None of them knew what the others were doing. None of them were accountable for their answers. And nothing ever got accomplished.

I have a saying:
“The only reason to call your insurance company is to find out where to write to.”

Call the Insurance Commissioner?

People want to believe that there is someone out there to help them, when they are in Bad Insurance Trouble. A knight in shining armor. Someone who will deal with the big scary insurance company and make them do the right thing.

Many people assume that the Insurance Commissioner is that person.

So not so. I am not saying that—out of all the fifty states—there is no Insurance Commissioner who will help you out when your treatment is denied. Out of the hundreds of cases that I have either been directly involved in or heard about, this has happened once or twice.

In other words … don’t count on it.

If you think that the job of the Insurance Commissioner is to fight insurance companies, or to keep them on the straight and narrow, you would be wrong. The job of the Insurance Commissioner is to be “keeper of state insurance rules and regulations.” That is what they do, and that is what I use them for.

When it comes to insurance law, each state is like a different country. Each state has its own body of statutes, codes, legal definitions, and regulations. Most insurance commissioner websites have a database of these regulations. When I suspect that an insurer is violating the law, I check their behavior against that state’s statutes. When I find an embarrassing violation, I put it in the appeal—very intimidating to insurers.

Sometimes I call the Insurance Commissioner’s office to inquire, “Can they do that? What is the number of the revised statute?” That is the Insurance Commissioner’s job.

Insurance Commissioners do not fight appeals. All that you can accomplish there is to file a complaint against your insurer. You will fill out the forms, and they will send you a letter a few months later, stating that they looked into it.

You will find no knight in shining armor at the Insurance Commissioner’s office. You are going to have to face off against the insurance company yourself.

Call a lawyer?

You understand that the insurance company won’t help you. You understand that the Insurance Commissioner won’t help you.

Lawyers are always there to defend us, yes? Not necessarily.

  1. Lawyers are generally not interested in denial of care cases. Why? Because it’s not a good business move, there is no money in it. If you win a denial of care case, there are no damages involved—you haven’t let them damage you yet. When we win a denial of care case, all we get is our treatment.
  2. Many of us who are fighting our insurance companies have no money to pay a lawyer.
  3. No court case involving lawyers is going to move fast enough to save your life.
  4. The only way to win a case against insurance companies in court is to either have the wrong leg cut off, or to be dead.

We really don’t want to be dead; that is why we are going through all this. See where I am going? There is no caped crusader, no social service agency, no benevolent organization that is going to fight your appeal for you.

This is your hero’s journey. Arm yourself, fight it yourself. Win it yourself, and the sweet victory will be all yours.

Next Excerpt 6 “Where Are the First Three Places to Go When Your Insurance Company Denies”
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