Marketplace Money (American Public Media)
KAI RYSSDAL (HOST): You get home one day and there’s a letter from your insurance company. It’s a denial of your most recent claim. Maybe for the treatment your specialist told you you absolutely need. The same one, the insurance company says isn’t medically necessary. Well, take heart, because Helen Palmer reports from the Marketplace health desk at WGBH. A denial is not the end of the story.
HELEN PALMER (REPORTER): Don’t just stuff that envelope in a drawer and don’t despair. You have rights, remedies and allies.
JERRY FLANAGAN (HEALTH POLICY SPECIALIST, FOUNDATION FOR TAXPAYER AND CONSUMER RIGHTS): If you get that mailer in the mail and it says the insurance company is not gonna pay, call them up and then there’s a five-step process you need to go through to make sure the insurance company is paying what it should.
HELEN PALMER (REPORTER): That’s Jerry Flanagan, one of the allies. He’s the health policy specialist
at California’s Foundation for Taxpayer and Consumer Rights, which will help you fight a denied claim wherever in the country you live. Flanagan says the most vital step is to document everything. Who you spoke to on the phone, when, why they said the claim was denied. Next in your five-step program, appeal to the insurance company in writing, says Flanagan.
JERRY FLANAGAN (FTCR): They’ll have a process internally that allows a customer to complain and appeal a decision to not pay for either a hospital or doctor visit.
HELEN PALMER (REPORTER): Let the hospital or doctor know what’s going on. You don’t want them dunning
you for cash the insurance company should be paying. If you’re turned down again, Flanagan says it’s time for the heavy guns.
JERRY FLANAGAN (FTCR): Most states, about 42 states in the country have an external review process where a regulator, usually a Department of Consumer Affairs, will do an independent review of that decision to deny the claim.
HELEN PALMER (REPORTER): As well as consumer advocates, the states’ top lawyers are in your corner. Richard Blumenthal’s the attorney general of Connecticut.
RICHARD BLUMENTHAL (ATTORNEY GENERAL OF CONNECTICUT): We advocate for people. We fight for them. If necessary, we go to court.
HELEN PALMER (REPORTER): Blumenthal says states have clout here. They license insurance companies, so the companies listen.
RICHARD BLUMENTHAL (ATTORNEY GENERAL OF CONNECTICUT): We have done thousands of these cases. And we succeed in more than 95 percent of them, which is a frightening statistic because, think of all the people who could and should have come to us to advocate for them.
HELEN PALMER (REPORTER): Typically, the attorneys general take on insurance companies in the individual market. Under federal law, you can’t sue if you get coverage through your job. You still might be able to get your bills reduced or forgiven, though. But you won’t get a deal if you don’t ask. Andrew Cohen is with the Access Project, a consumer watchdog group. He and all the patient allies stress you must fight the denial, even though it takes time.
ANDREW COHEN (ACCESS PROJECT): Some of these companies rely on the fact that most people don’t take that extra effort and it is extra effort. Some of my clients say, you know, it’s like another part time job doing this work, but it’s always worthwhile.
HELEN PALMER (REPORTER): Sometimes, though, a denial can be devastating when you don’t have time.
JERRY BERK (PRINTING COMPANY OWNER): Thirty days is how long they can keep the perfect match.
HELEN PALMER (REPORTER): 64-year-old Jerry Berk owns a printing company. He’s had leukemia since 2004. Despite multiple blood transfusions, round on round of chemotherapy have destroyed his bone marrow. His oncologist said a bone marrow transplant was his best, indeed, only hope. They found him a donor, a perfect match. But the insurance company says chemo is the way to go. They’ve turned down Berk’s request three times.
JERRY BERK (PRINTING COMPANY OWNER): I was extremely angry. It’s like they’re playing God with me. And I really don’t understand that.
HELEN PALMER (REPORTER): Berk’s only recourse now is a health care attorney. He chose Mala Rafik. She radiates hope and optimism. She says by law, insurance companies must consider individual circumstances.
MALA RAFIK (HEALTH CARE ATTORNEY): You wanna believe that these are monolithic insurance companies who don’t care and are driven by the bottom line. But more often than not, they aren’t.
HELEN PALMER (REPORTER): Real people handle claims and requests for treatment, says Rafik. They can help you. Be polite. Make them your friends. Above all, keep fighting.
MALA RAFIK (HEALTH CARE ATTORNEY): The reason why so many claims are denied is because too many people give up. Just don’t ever give up.
HELEN PALMER (REPORTER): Rafik says there’s a whole network of lawyers like her who’ll help. Often,
they work pro-bono. She thinks Jerry Berk will get his transplant. Certainly, that’s what his wife Nina is begging for.
NINA BERK (JERRY BERK’S WIFE): I can’t see — I just don’t understand why this insurance company will not, you know, give him the chance to live.
HELEN PALMER (REPORTER): In Boston, I’m Helen Palmer for Marketplace Money.
KAI RYSSDAL (HOST): We’ve got all sorts of information from Helen’s story online. It’s at Marketplace.org.
