How to File a Health Insurance Appeal for a Denied Claim Cancer

July 20, 2023

Cancer.  Just hearing that diagnosis can strike fear into one’s heart. According to the CDC, 1.7 million people are diagnosed with cancer each year. The disease is devastating — physically, emotionally, and financially. Medical care is costly; $185 billion dollars are spent annually on treatment.

Those suffering from cancer work closely with their medical teams to identify and access the best options for their illness. Luckily, research is continuous and new treatments are regularly discovered. Those who have medical insurance expect that their treatment will be covered, that their procedures will be approved, and their providers paid in full.  Unfortunately, the process is not as simple as it seems. In fact, tens of millions of cancer claims are denied every year.

If you have been diagnosed with cancer and your medical claim has been denied, you have options. Do not accept your insurance company’s response as final.

You can file an appeal with your insurance company.

Managing this process on your own can be challenging. The assistance of a Oklahoma health insurance claim denial lawyers who is experienced in cancer treatment denials can prove beneficial. This professional can manage the health insurance denial appeal on your behalf.

Denied Claim Cancer

Reasons Why This Happens

Understanding why your claim was denied is critical in the cancer insurance appeal process. Below we have shared some of the most common reasons this happens.

• Incomplete documentation and submission errors
• Missed filing deadlines
• Experimental treatments
• Off-label drug use
• Treatment declared not medically necessary
• Cosmetic procedures
• Out-of-network providers.

Clearly, some of the reasons for the denial can be quickly and simply addressed, and coverage rectified, while in other instances the process becomes more complex.

How to File a Health Insurance Appeal

A Roadmap to Follow

Knowledge is power, especially when it comes to addressing denied cancer claims.  Understanding what to do and doing it correctly can help increase your chances of a successful appeal. The steps in the process include:

Reviewing Your Health Insurance Policy: Before doing anything, it is critical to understand your specific policy, both what it covers and its exclusions.  The language can be confusing; this is one of the areas in which a health care insurance denial attorney can help. Policies may change, so even if you have had the same coverage for years, you should take the time to read through the current version.  The insurance company’s decision may be based on old policy information, and recognizing the extent of your coverage is critical.

Determining the Reason for Denial: Based on your policy and the denial letter from your insurance company, you should be able to ascertain exactly why your claim was refuted.  You want to make sure you understand the reason correctly, so when you move forward you address the issues appropriately.  The information provided in the prior section shares some of the reasons why denials occur.

Talking to Your Physician: Sometimes your doctor can be your greatest ally when dealing with cancer treatment denials.  Provide him or her with a copy of the denial letter from the insurance company and ask him to draft a document detailing the medical necessity of the treatment he has prescribed for which coverage has been denied.  Supplementing his letter with links to studies by reputable organizations (like the FDA) can be helpful.

Submitting an Appeal Letter: This letter should include certain specific details like your name, contact information, policy number, and service dates. It should also tell why the claim was denied and why you disagree, along with facts substantiating why it should be paid. You will want to give an exact description of the treatment you are requesting, including where you would have the treatment performed and who would be providing it.  It is important to attach supporting information (like a letter from your physician) to your appeal.  This can be critical in having the insurance company accept and pay your claim.  Engaging a health insurance denial attorney to help to write your appeal can help maximize your settlement.

Insurance companies often take appeals from individuals who are represented by an attorney more seriously.

Request an Expedited Review: Time is incredibly valuable, especially where cancer treatment is concerned. For non-cancer claims that are not urgent, you have time to request your case file and documentation. However, cancer treatment is different.  Waiting can be the difference between life and death.  In situations where timing plays a critical factor, insurance companies can fast-track the review process.

File for an External Review: The Oklahoma Insurance Department  advises that if your appeal is denied, you can request an independent external review. This process can be helpful; those reviewing your case are not affiliated with your insurance company and thus they have no need to deny your claim in order to protect the insurance company’s bottom line. Before taking this step, it is vital to speak with an insurance denial attorney because decisions rendered here could impact possible settlements through litigation.

If you are struggling with denied cancer treatment claims, engaging a denied health insurance lawyer to manage the process on your behalf is something to seriously consider. The process to resolve coverage issues regarding cancer claims can be incredibly complex. You simply don’t have the knowledge to manage it on your own. Besides, your time should be spent focused on your health, your recovery, and your family.

Addressing Cancer Treatment Denials Quickly Is Paramount

Doug Terry Law Is Ready Help with Your Cancer Insurance Appeal Process

Has cancer treatment for you or a loved one been denied?  If so, you have no time to waste. These life-saving medications and procedures are often time sensitive; resolving your insurance disputes efficiently can make a very real difference.

Our team is well-versed in managing the appeals process. We understand insurance company operations, why they make the decisions they make, and how to address them efficiently and effectively.  We handle the entire process for you, so you can focus on your health and well-being.

Insurance companies regularly, unfairly, and unreasonably deny coverage to those impacted by cancer, putting the health of their policyholders at further risk. Our firm was founded on the belief that individuals deserve quality service from their insurance companies, and covered claims should be paid in accordance with policy guidelines in a timely fashion.

We have made a long-standing commitment to helping those who have been treated unfairly address their issues with their insurance companies. Our overarching goal is to maximize their settlements.

Let us help you move forward. Your health deserves to be protected. We will leverage the resources of our entire firm on your behalf.  Contact us at 405-463-6362 to schedule a consultation. Because we appreciate that you have no time to waste, we are available to meet with you immediately.