Information and Guidance
The following information could save you time and trouble if your health insurance denies you treatment or tests recommended by your doctor.
Procedures
Call your HMO's customer service number.
State your complaint, and find out how their internal appeals process works. Immediately send them a letter that puts your complaint in writing.
Follow your HMO's appeals process.
I found that I could not appeal to any outside agency until I had done so.
Look for allies.
Your doctor's support is critical. Ask him or her to write to your insurance and explain the medical necessity of the treatment or test. Other potential allies include:
- Your benefits manager at work
- Professional organizations to which you belong
- Federal Employee Health Benefit Program at the Office of Personnel Management (for federal employees) 1.888.767.6738 or (202) 606.0500 in Washington, D.C.
- State and local medical societies
- State and U.S. senators and representatives
- Patient Advocacy Groups at the local, state, and national levels.
Patient Advocacy Groups
The Patient Advocate Foundation sounds like it could be a potentially important ally. (I didn't learn about them in time to help with my own situation.) Their mission is to resolve matters between patients and insurers through mediation. Contact them while you are still going through your insurance's internal appeals process. Note that a major limitation is that they offer assistance only to people suffering from specific diseases.
- Patient Advocate Foundation
- 1.800.532.5274
- 725 15th Street NW
- Suite 503
- Washington, DC 20005
- www.patientadvocate.org
- Center for Studying Health System Change
- ph 202.484.5261
- 600 Maryland Ave. SW, #550
- Washington, DC 20024
- E-Mail:hsclynnemartin@hschange.org
- I found no Web site address, so just google their name and click onto it.
- Families USA
- ph 202.628.3030
- fx 202.347.2417
- 1334 G St. NW
- Washington, DC 20005
- www.familiesusa.org
- HARP
- http://www.harp.org/ includes discussion of ERISA issues.
State Agencies and Advocacy Groups:
Here are some state agencies and advocacy groups in Pennsylvania, where I now reside. I also included one from when I lived in NH. Please feel free to E-Mail me about any you may know about from your state Maybe we can compile a directory.
- M. Diane Koken, Insurance Commissioner
- Ph 717.787.0442
- Fx 717.772.1969
- State of Pennsylvania
- 1326 Strawberry Square
- Harrisburg, PA 17120
- www.ins.state.pa.us/ins/site
- PA Department of Health
- Ph 877.724.3258
- HMO/Managed Care Complaints: 888.466.2787
- P.O. Box 90
- Health and Welfare Building
- Harrisburg, PA 17108
- www.dsf.health.state.pa.us/health
- Pennsylvania Citizens for Fairness
- Ph 888.870.3247
- Fx 215.754.4101
- 1735 Market Street, Suite A-509
- Philadelphia, PA 19103
- www.pacitizensforfairness.com
- Guardian Nurses Health Care Advocates, Inc.
- Ph 215.836.0260
- 8802 Bailey Road
- Wyndmoor, PA 19038
- www.guardiannurses.com
- New Hampshire Citizens Alliance
- Ph 603.225.2097
- 4 Park Street, Suite 403
- Concord, NH 03301
- www.nhcitizensalliance.org
Recommendations
File a complaint with your state insurance commissioner
(or state "department of insurance" - same thing.)
The effectiveness of this varies state to state. Some insurance commissioners are insurance industry insiders who take a government job for a few years, and may rubber stamp your HMO's decision. In any case, I found that I had to file with the I.C. before I could file with my state attorney general or file a lawsuit.
File a complaint with your state attorney general.
I've been told that in some states this is the regulatory agency that the insurance companies fear most - but mine didn't handle health insurance matters and referred me back to the insurance commissioner.
File a lawsuit that wont eat your life's savings.
You or a loved one is sick and need treatment ASAP, so obviously anything above is preferable to litigation. But if you're forced to go this route, consider the low cost options.
Contact your state bar association about pro bono (free) legal services.
But to qualify you must be destitute. (My gross salary at the time - $22,000 with no dependents - was way too high.)
Contact your nearest EEOC (Equal Employment Opportunity Commission) office if there's a chance your condition might qualify as a disability for which you are being discriminated against.
LOOK INTO THIS EARLY. You don't have much time to file a suit under the EEOC. I got two different estimates, but both were well under one year from the time of the discriminatory act, and I was too late.
Contact patient advocacy groups to see if they offer legal assistance.
(If they do, you may need to meet pro bono poverty guidelines.)
Consider participation in a class action suit.
On the one hand, this brings little individual restitution - I was told something in the range of $10,000 to $15,000. On the other hand, it costs the individual almost nothing in terms of time or money, and successful class action litigation has a larger impact on legislation than an individual lawsuit.
It's not easy to find law firms that do class actions against managed care.
Here are the two I found:
- Pomerantz, Haudek, Block, Grossman Gross
- Ph: 212.661.1100 or 1-888-4-POMLAW
- 100 Park Avenue
- New York, NY 10017-5516
- With offices in Chicago and Washington, DC.
- www.pomerantzlaw.com
- Herman, Herman, Katz & Cotlar
- Ph: 504.581.4892
- Fx: 504.561.6024
- 820 O'Keefe Avenue
- New Orleans, Louisiana 70113
- www.hhkc.com
Retain your own lawyer.
Unless you're wealthy, you'll need a lawyer who'll take your case on a contingency basis, meaning you don't pay them unless you win. It isn't easy. Few lawyers are interested in taking on managed care because they know the legal deck is stacked against the rights of patients. If your plan falls under the ERISA laws - best to find out early on - winning will be next to impossible.
Even if you find a contingency lawyer, it's still going to cost you between $10,000 and $20,000 in related expenses such as paying for your doctor's expert testimony.
If you're still not discouraged, you could start by searching www.lawyers.com. Enter "health insurance" for type of lawyer and along with the name of your state.
Although my own search in the year 2000 yielded 37 listings for New Hampshire, not one of these firms wanted to take my case, and a number of them were already being retained by my HMO. (A sign of the times: in Nov. 2004 I repeated the search out of curiosity and got zero hits.)
It was only after I moved near Washington, DC, that I finally identified a lawyer willing to take health care cases on a contingency basis. Dr. Welch continues to be active in heath care law.
- Bryant L. Welch J.D., Ph.D. & Associates
- Ph 843.686.2260
- Fx 843.341.9331
- 19 Shelter Cove Lane
- Suite 204
- Hilton Head Island, SC 29928
- www.bryantwelch.com
Tips
Better to hear this now than learn the hard way...
Keep it civil.
Just looking at the process I've outlined above should make it clear that trying to reverse your health insurer's decision to terminate or deny care may be the greatest ordeal you've ever experienced outside of developing a health problem. Anger and even despair in the face of a group of people that are deliberately jeopardizing your health or that of a loved one to increase their corporation's profit margin by some tiny increment is only human.
But tell it to your therapist in whatever limited number of sessions you might have if you happen to have mental health coverage, and not your HMO. Their well-practiced "professionalism" will only leave you feeling like a fool, undermine your credibility, and could even lead you to blurt out something you needn't have shared and which they will be able to use to your disadvantage.
On the phone and in writing be rational, factual, and concise. Share with them only what needs to be shared and what helps make your case regarding the specific decision you are appealing.
Remember that you are already facing a system that's stacked against you. If you direct anger at managed care personnel you'll also have to deal with their antagonism. No matter how outrageous their responses, swallow hard and pretend to assume that you are dealing with people of good will who care about your health and want what's best for you.
Keep careful records.
Starting with your initial complaint call, which begins a traceable record of your grievance, log every conversation and retain copies of all correspondence. In phone logs, include the person's first and last name, title, phone number, date, and time. If they tell you anything important over the phone, get it from them in writing. It may seem inconvenient, but inconvenience is relative, and in the long run - and it will probably be a long run - it will save you time and trouble.
Move fast.
The internal appeals procedures of health care corporations would "almost seem" to be deliberately designed to take as long as possible. They have any number of stages and take at least three or four months, assuming that from your end, you are keeping things moving forward as fast as possible.
Buy a fax machine.
This is practically a necessity. The ability to make copies at home will simplify your record keeping, while faxing will speed up correspondence, giving you the ability to immediately put whatever records you want into the hands of anyone who's interested without having to make copies of them beforehand. Purchasing a fax machine buys time.
Voice your concern.
Healthy or sick, if this outline of what so many sick Americans are having to go through sickens you, please let your state and national legislators know that you demand serious health care reform - and serious campaign finance reform. Until there's major campaign finance reform, the insurance lobby will be free to continue purchasing the legislation that meets its interests.
It isn't the kind of freedom America should stand for.
U.S. Congress and State Representative Links
For your representatives in the U.S. Congress, see the New York Times online congressional guide: http://capwiz.com/nyt/home/
For your state and local representatives, navigate http://www3.capwiz.com/congressorg or do a web search that includes the words, "state representatives."
Pennsylvania Citizens for Fairness, www.pacitizensforfairness.com, has an alphabetized list of PA legislators on their "Contact your Legislator" link.
The National Voting Rights Institute appears to be the major national organization fighting to maintain American democracy through serious campaign finance reform. Contact information:
- The National Voting Rights Institute
- 27 School Street, Suite 500
- Boston, MA 02108
- Ph: 617.624-3900
- Fx: 617.624-3911
- Email: nvri@nvri.org
- www.nvri.org
Other Information
Musings about the goings-on in American health care from Matthew Holt, a general health care consultant.
- The Healthcare Blog
- http://www.thehealthcareblog.com
