The Policy and Policy Language
Insurance companies (including health maintenance organizations, managed care organizations, and similar entities) are not in the business of giving away money, or expending money if they can avoid doing so. All payments are governed by the language (contract provisions) of the policy, by governing law, and by public policy. Unfortunately, what you believe is fair, right, and just does not constitute "public policy." All services requested for for you or for your child are scrutinized for compliance with the policy terms, and limitations or exclusions. Families frequently have disputes with insurance carriers over which services are medically necessary. Even though you feel that a service is medically necessary and your physicians or health care providers agree completely, the insurance company may disagree or refuse to pay.
It is important to keep a copy of all correspondence to and from an insurance company (and this does include your HMO, MCO, etc.). If letters to the insurance company do not result in the coverage you believe your or your child is entitled to, contact your state insurance dept. State Insurance Departments are designated state agencies which act as go-betweens between consumers and insurance providers. These agencies are responsible for making sure that all policies and contracts issued by private insurers are within state insurance law guidelines, for providing consumer education about insurance, and for investigating complaints against insurance brokers, agents, and companies. Additionally, these agencies may impose sanctions (including fines and revocation of licenses) against insurance providers found guilty of violating insurance laws and regulations.
Complaint or Going to Court
If you feel that you have received unfair treatment from an insurance provider, you may file a written complaint with your state's Insurance Department, which can then investigate your claim. Sometimes, your only recourse in a dispute may be to take the insurance company to court. For example, the terms of your insurance policy may not be in compliance with the law, but the company may deny it. For example, one family’s policy stipulated that they were entitled to only $300,000 in coverage when by law they were entitled to $3,300,000 worth of coverage. The insurance carrier refused to provide this level of coverage, however, until the highest court in Maryland ordered them to pay. Staab v. American Motorist Insurance Co., 345 Md. 428, 693 A.2d 340 (1997).
Usually the resolution of insurance disagreements hinges upon the contents of records created along the way — medical records, insurance applications, insurance submissions and correspondence. These are then analyzed against the contracts and the law. When your child’s records are fragmented, and when relevant items are undocumented or incomplete, your family is much less likely to get the coverage you need. The next section therefore describes some strategies that will help you keep your and your child’s records in order.