by Debra Thomas

One day last September, I received a surprising email from CCHI, and the timing could not have been better.

I’d been sitting at my desk fuming, because I had just received a letter from Kaiser Permanente rejecting my application for health insurance. As a recent retiree who’s too young for Medicare, I’d already been frustrated trying to find a reasonably priced individual policy, but this took the cake!

Although I’m healthy and don’t take any prescription drugs, the letter explained Kaiser had rejected me because of “serious medications” listed on my application. That made no sense, but since it was clear Kaiser didn’t want to insure me, I decided appealing the decision would be a waste of time and effort.

So I contented myself with fuming, until that email popped into my inbox.  It included a link to a story headlined “Up to Half of Insurance Claims Appeals Are Successful, GAO Finds.”  The study focused on denied claims, not denied coverage, but I figured that if insurance companies so frequently reversed themselves on claims, they might just as likely reverse themselves on coverage. I decided to file an appeal with Kaiser.

It took some time and effort to make the case. I wrote a succinct letter and submitted detailed records to counter each of the reasons Kaiser had listed for denying my application.  Six weeks passed without a response, so I called the company and was told they’d never received my letter.  I resent it, this time by registered mail. A few weeks later, my Kaiser membership card arrived. There was no acknowledgement of my appeal, and no explanation of why the initial decision was reversed, but I didn’t care. I had coverage, and that was enough.

The GAO study found half of appeals are successful, so I knew I was pushing my luck but decided to try another one. My previous insurer had denied payment for a shingles shot I’d received, even though two different representatives had told me it would be covered. I called the company and a wonderful representative went the extra mile to research my claim. I received a check for the entire cost.

In an ideal world (or a country with an efficient and effective health care system), consumers wouldn’t have to spend frustrating hours dealing with insurance company bureaucracies to correct their mistakes.  But the moral of my story is that, until that day comes, appealing an insurance company decision can be worthwhile.  It takes time, persistence, good record-keeping and good luck in finding someone at the company willing to work with you on a resolution.

And, of course, CCHI’s on-going efforts to hold insurance companies accountable and educate consumers about their rights!

Debra Thomas recently retired from a career in communications and public policy, most recently as VP of Communications and Education for the Colorado Health Foundation.  She continues to stay involved in health policy issues through Boomers Leading Change in Health, as a volunteer with CCHI and as a consumer representative on CORHIO’s Policy Committee.

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