Health Insurance Claim Denied? See What US Insurers Said Behind the Scenes

Healthy Plan

This story was originally published by ProPublica.


Learn how to request your health insurance claim file, which can include details about what your insurer is saying about you and your case.


When a health insurance company is deciding whether to pay for your medical treatment, the company generates a file around your claim. All the records associated with your case should be part of your file. This includes documents explaining the reasons your claim was denied.


You have a right to see this file. Federal regulations require most health insurance plans to give people an opportunity to review documents related to their claim for free. So if your insurer talks to your doctor, if a nurse takes notes, or if two people speak about it on the phone, all of those records should be available to you.


“It’s a treasure trove of information,” said Juliette Forstenzer Espinosa, a health lawyer and senior lecturer of health policy at George Washington University. “But most people have no idea how to get it.”


Health insurers rarely advertise that people can access their claim files, Espinosa said. Where guidance exists, it is often embedded deep in denial letters. Few offer templates or even give instructions on their websites.


Patients who make it through the records request process get information that can be revelatory. Some told us they received case notes exposing how they had been funneled into programs the health insurance company deployed to cut costs. A few obtained audio recordings of phone calls showing company staff introducing errors into their cases.


And others, such as former Cigna patient Lee Mazurek, found out exactly how much companies projected saving on their cases. Mazurek had been on a treatment regimen for nearly nine years that was keeping his Crohn’s disease at bay. Changing it, a Cigna employee estimated, could save more than $98,000. (Cigna spokesperson Justine Sessions said the insurer only suggests changes when clinically appropriate and that cost is never the sole determining factor. She said Cigna does not directly benefit from such savings.)


Taken together, these documents can offer a window into the opaque system of health insurance denials. Details in them have helped us report on some of the country’s largest insurance companies and their attempts to cut costs at the expense of patient well-being. health-insurance-claim-denied”>Continue Reading…


Additional reporting by Patrick Rucker and David Armstrong (ProPublica)



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