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help wordsmithing insurance appeal

My health insurance is managed by third parties. Over the years I've had A LOT of issues with them, as have my preferred providers (Billing, saying they cover stuff/people and then not, etc.).

In 2009, I started seeing a therapist with a masters of counseling/LHMC degree. She was covered under my plan. In 2010, I continued to see her. We had a new third party managing the insurance, but they continued to pay my therapist from January through September of 2010.

NOW, my insurance says that my therapist did not meet their criteria in 2010 (only PSYCHIATRISTS were covered) and they want $884.00 back from my therapist, or from me.

I plan to appeal on the grounds that they are supposed to be the managers of this plan and that they should have caught this mistake before it ever went this far. That's a lot of dough for me and my therapist. This seems like something done "in bad faith".

How can I word my appeal letter to let them know that this is their mistake? I am considering dropping into the letter that I will not hesitate to go to the Washington State Insurance Commission for help.

Please advise.
Thanks.

(PS - As of 2011, they are covering MC's and LHMC's.)

justwondering asked in Insurance about 1 year ago | Report

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2 Answers

  • Qlandav2ex_small
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    Contact the Office of the Washington State Insurance Commisioner for assistance. They are the entity charged with consumer protection in dealing with insurance providers, which you clearly need. Don't take them on yourself, make a complaint. Faced with dealing with the folks that decide whether or not they are allowed to do business in this state, you will get much more fair consideration.

    http://www.insurance.wa.gov/

    Russ Campbell, NWEBS answered in Insurance about 1 year ago | Report
    2 comments by Russ Campbell, NWEBS and justwondering…
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  • 171004_187797394575098_171125202908984_544001_2007695_o_small
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    Sound Advocates PLLC

    Specifically related to wordsmithing: you may be on the right track with "bad faith." Additionally, if you have a strong claim, a citation to Washington law could add weight to your words.

    Some coverage denials may violate the Consumer Protection Act (CPA), RCW 19.86 et seq. Or, an unreasonable denial of coverage may violate the Insurance Fair Conduct Act (IFCA) approved by voters in 2007, RCW 48.30.015.

    Both of these acts provide for an award of attorney fees and potential 3x damages to a successful plaintiff. Insurance companies may not risk going to litigation against a strong claim. However, only certain practices fall under the CPA, and IFCA exempts many health insurance providers. Common sense would be to check their applicability to your case before raising the specter of litigation.

    Also, as Russ Campbell mentioned, the commissioner's office can be a good source of assistance or information.

    Of course, without knowing details of your case, I cannot give you legal advice. However, I hope this helps if you choose to draft a letter.

    Sound Advocates PLLC answered in Insurance about 1 year ago | Report
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