What can, or must, I do when a health insurance company or plan refuses to pay a claim or provide a benefit or service?

If a health insurance company or plan denies a claim or refuses to provide a requested benefit or service, it is very important that the insured or member immediately review the policy, plan or evidence of coverage document relating to claim or benefit denial, appeal or grievance procedures. Most often, there is a requirement that the insured or member appeal a denial of a benefit or service with a written appeal within a period as short as 15 to 60 days. In addition, there are typically multiple levels of appeal or grievance, which are mandatory and which involve subsequent short time limits. Appeal or grievance procedures, depending on the policy or plan, either require that final determinations of entitlement to benefits or services be made by required arbitration, or they allow the insured or member to file a lawsuit, but only after exhausting the appeal or grievance procedures set forth in the policy or plan. While legal assistance from an attorney is not necessarily required at the initial levels of appeal, it is strongly urged as soon as possible if the amount involved is large, or the insurer is contending the treatment you need to live is "experimental" or the matter is going to any arbitration or lawsuit. Rest assured that the health insurer or plan will almost certainly be represented by an attorney, and s/he or he will be out to have your claim denied.