Filing a Medical/HMO Insurance Claim
Understand your rights and responsibilities as a claimant. Unless your claim is ERISA Preempted (above) certain principles under the laws of most states have evolved to help protect you in the claims process. These rules can be very important in the handling of a given claim.
You should be familiar with them. Generally, insurance companies are precluded from:
- making deceptive or misleading representations to insureds either at the time of sale of an insurance policy or with respect to a claim;
- under-settling valid claims;
- engaging in unreasonable delay in the settlement of a valid claim;
- conducting prolonged or unfair claims investigations; or
- compelling policyholders to sue them in order to collect payments due under a policy.
Insurance policies contain an “implied covenant (promise) of good faith and fair dealing.” This means that both sides must treat each other fairly and reasonably in all aspects of the handling of covered claims. Failing to do this can result in different consequences, depending on your state. The point to remember is that this duty exists and is a serious one.
If you write to your insurance company in regard to a claim, here are some simple rules for you to follow:
- Never use harsh, intemperate, extreme or threatening language when corresponding with an insurance representative. Do not say things like: “I’m going to sue you for everything you’ve got.” Or: “Keep it up and I’ll wind up owning your company”. Such letters will come back to haunt you.
- Do not send CCs of correspondence to VIPs such as Senators, Members of Congress, CNN reporters, The Pope or other luminaries. This never has the desired effect.
- Keep your correspondence concise, rational, articulate, reasonable and accurate. If you are going to send any CCs at all, send them to the Regional Claims Manager or the Vice President for claims in your company’s home office.
- Save everything you write and all responses from the company. Keep these letters in your insurance binder.
- Confirm in writing any significant oral representations or statements made to you. File these as well.
Save any significant letters or memos to or from third persons (such as contractors, physicians, appraisers or other experts) if they pertain to a claim or other insurance matter.
Next: The Claim Process