How to Dispute a Health Insurance Claim

Like every other financial document you receive, it’s important to check over each and every record you get from your health insurance company. Most importantly, always keep a running tally of each family member’s medical charges, as well as an up – to – date total of your family’s combined medical expenses.

Sometimes, deductibles can be miscalculated, and you could end up paying individual deductibles when the family deductible was already met, or maybe even exceeded!

Medical insurance plans vary, but several do institute “out-of-pocket limitations.” This means, that, once you and your family have accrued and paid out a set amount for covered medical care, the insurance company will then pay 100 percent of any covered costs for the rest of that calendar year.

If you have this feature on your policy, the running tallies I spoke of earlier will enable you to accurately keep track. You surely don’t want to pay more than you have to!

Your Health Insurer Won’t Cough Up the Money?

You’ve probably heard the old saying that you “Can’t fight City Hall!” Insurance companies are even bigger than your average city hall. They’re giant conglomerates that hold the reins of a great deal of financial, as well as political, powers, but … guess what? You can fight City Hall, and you can lock horns, if need be, with your insurance company!

A common problem is the denial of a claim. Any and all claims that your insurer may refuse to pay means, initially, “Take a deep breath and open your checkbook… wide!”

You should take appropriate steps to remedy the situation if you feel a claim was wrongly denied.

How To Claim What’s Rightfully Yours!

1. Take the denial letter to your Benefits Administrator at your place of employment. Explain the situation to them. The administrator might have the answers “right off the bat” as to why your claim was denied. If he/she can’t find a plausible reason, they might call the insurance company for you. If not, at least they can offer professional advice on how to proceed.

2. You might very well end up calling the provider yourself. If you do, ask to speak to the Claims Processing Department. When you reach the appropriate employee, find out why – in plain English – your claim was denied.

3. If you’re not satisfied with the answer you get, then the next step is to ask to speak to their supervisor.

You’re problem could be a simple mistake, like a wrong diagnosis code, for example.

This happened to me once: a supplemental insurance company argued that a family member did not spend a part of their hospital stay in the Intensive Care Unit because, according to the billing code, they spent their entire hospital stay in a regular room. Wrong! We disputed the claim. It was found that the wrong code was used, and the problem was resolved.

4. If you’re still sure that your claim should have been accepted, and the insurance company still won’t budge, don’t give up! There’s still hope!

5. Sit down and draft a letter. Take your time and include all of the pertinent details of your problem. Tell why you think your claim should not be denied; give dates, times, and names if it will help you build your case. After you have finished your draft, go over it carefully. Make sure the information is correct. Then, use your draft to write – up your formal complaint letter. Spell check – it and check it for proper punctuation.


Sign your letter and print up several copies; keep one for yourself! You’ll want to send a registered copy via the U.S. Mail to your insurance company first. Also, send a copy to your state representative, Office of Consumer Affairs of your state’s Attorney General’s Office, Department of Commerce, and your state’s Department of Health.

Your letter is bound to reach up “somebody somewhere” who can help you out. Either you’ll find at least one advocate who can assist you in fighting your case, or else you’ll hear back from someone who can explain to you exactly why your claim will not be paid.

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