Having Insurance Problems?

Document Everything

Documentation is your best friend! This includes letters, faxes, and notes (from all phone conversations). Highlight the key sentences that indicate the insurers intent to question the necessity of, delay the reimbursement/authorization for, or decline coverage for your Lyme disease (LD) care.

Tell Everyone You Need Help!

Your insurance company - Give the insurer a chance to fulfill its commitment! Do not become alarmed until you are sure the insurer is interfering with your medical care. We have seen many occasions where problems are really due to miscommunication or incomplete documentation. Please make sure you have clearly communicated your position to the insurer before contacting your Insurance Commissioners.

Your employer - Contact the employee benefits area and request assistance. Your employer does have the right to insist on payment of medically necessary care. Sometimes the insurer's bad faith behavior has so outraged the employer, that the company threatened to move or actually did move all of its insurance coverage to another insurer.

Write to every Insurance Commissioner in the states where you live, you work, your employer's headquarter is located, and where you receive your medical treatment.

Request assistance from the State & Federal Representatives where you live, you work, you own property, your employer's headquarters is located, and where you receive your medical treatment.

Include at the top of every letter...

Your name, address, home phone #, work phone #, fax #, and the best time and way to reach you
Insurer's name
Insurance plan administrator's name
Employer's name
Policy and plan number
Insured's name and insurance number
Name of the family member being denied coverage or experiencing insurer interference with LD medical care.

ERISA - Self-Insured Programs

State Insurance Departments have no authority over Self-Insured programs. Lawsuits which are initiated to force an insurance company to pay for extended Lyme disease treatment are covered by the federal ERISA (Employee Retirement Income Security Act) which governs these types of claims if the medical insurance was obtained through employment. The claimant must exhaust all appeal processes set forth in the major medical insurance company's booklet and obtain written denials from the insurance company before a lawsuit can be properly maintained against the insurance company. Documentation is key to proving your compliance. The courts have held that a failure to exhaust all administrative procedures (including the appeal process outlined in the booklet) is a proper basis for dismissing a lawsuit under ERISA.

Patients have a right to receive a written denial of their claims and appeals. If the insurance company fails to provide a written denial, a complaint should be filed with the Superintendent of Insurance in the state where the patient resides. Send all complaints with the insurance company by certified mail, return receipt requested.

 

Before you file a complaint

Consider whether or not you have a legitimate complaint. If your physician recommends LD-related medical care and your insurance company refuses coverage, you have a legitimate complaint.

Find others in the same situation and share information.

Find alternative treatment (usually less effective) to hold you over while you are fighting.

Write a letter to the insurer and to your employers benefit area requesting a reevaluation, clarifying the medical necessity for the care. State that the insurer (and the insurer's consultant) will be liable for any hardships and medical damage incurred due to the delay in diagnosis or treatment. Request a return receipt and ask for a response within 5 business days.

Ask for assistance from several insurance departments. Insurer's Board of Directors receive copies of insurance department complaint letters and are required to take action.

Go public! Send copies of all correspondence to local or national media. This includes the insurers original letter of denial and other correspondence.