Domna Antoniadis is a senior staff attorney with New York Legal Assistance Group’s Legal Health Unit, conducting legal clinics at Bellevue Hospital Cancer Center. She received her undergraduate degree from Fordham University and her J.D. from Fordham University School of Law. She has co-authored and presented on patient navigation in the cancer setting, medical legal partnerships, and public health.
Disclaimer: The information and materials made available in this blog are for informational purposes only and not for the purpose of providing legal advice. You should contact your attorney to obtain advice with respect to any particular issue or problem. Use of and access to this website or any of the links contained within the site do not create an attorney-client relationship.
Health insurance concepts to keep in mind
Understanding how health insurance generally works can make it seem less overwhelming. Key concepts include:
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Health insurance is a contract. Insurance policies are partially governed by contract law. You or your employer agree to pay a set premium, participate in cost sharing, such as payroll deductions, co-pays, and/or deductibles, and follow the contract guidelines. In return, your health insurer (often referred to as the “Payer”) agrees to cover certain services in your policy and those required by law (even if it isn’t in your policy or the language is vague). It’s helpful to think of your insurance coverage as a contract because it allows you to better advocate for yourself and for appropriate coverage. It also helps you set realistic coverage expectations. For example, if your health insurance policy says that radiation therapy for a certain period of time or level of care is covered with no co-payment or individual allocation, then your insurer cannot come back and charge you for additional payments. However, if your plan specifically states that it does not cover a service, then that service may not be covered unless it meets the criteria for an exception. It is very important to review the “exclusions” section of your policy to be sure what the policy involves. Also, keep in mind that even services that are covered under the policy often require pre-authorization.
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Contra preferentum. This Latin phrase means that vague language in your health insurance policy will be interpreted in your favor. Let’s say your policy states an appeal must be made within 30 days, and you mailed it within 30 days but it was not received by the company within 30 days. Since in this example the policy doesn’t state if its wording means postmarked within 30 days or received within 30 days, the law might interpret this provision in your favor because the wording is unclear. Or if one part of your policy states, for instance, that cold cap therapy is covered but another part of the policy suggests that cold cap is excluded, then contra preferentum states that the ambiguity should be decided in your favor. Ambiguity is always interpreted in favor of the policyholder.
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Public policy overrules health insurance plan language. Due to the unique nature of health insurance, there are certain requirements mandated by law that you are entitled to, even if your health insurance policy says otherwise. For example, consider “cancer treatment fairness,” or oral parity, which means that your insurance will cover oral chemotherapy at the same level as intravenous (IV) chemotherapy. If your state mandates coverage for oral parity, then it doesn’t matter if your policy specifically excludes oral parity, because that conflicts with the state law. In some cases, public policy can overrule plan language even if there is no law in place. For example, if your policy states an appeal must be mailed within 180 days but you were in a coma during this time, then you should still be allowed to submit your appeal within a reasonable time after waking from the coma, even if the deadline has passed.
It’s important to note that because these are general concepts, they may not apply to all health insurance policies or situations and that state law and jurisprudence can affect how and whether these concepts are applied to specific circumstances. You are encouraged to consult with an attorney on any specific questions relating to your plan, its coverage, and applicable law.
Organizing information electronically
It can be difficult to stay on top of your health insurance, especially as you undergo treatment. These strategies can help you keep important information organized and accessible on your computer and online.
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Create a digital folder on your computer. Use this folder to save insurance-related documents and email correspondence, such as appeal letters, doctor letters, and copies of medical records. The main goal is to know where important documents are in case you need to use them. Consider sharing access to this folder with someone you trust in case you are unable to provide required information for your treatment.
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Create a login for your health insurance company’s website. This will allow you to quickly view your benefits online, send emails to a representative, and view claims. Once you’re logged in, browse through the site to get a sense of what type of information is there. Look for tabs titled “Claims” and “My Benefits.” Make sure your login and password credentials are sufficiently secure, complex, and not used for any other websites.
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Obtain and keep electronic copies of your Summary of Benefits (SOB), Explanation of Benefits (EOB), and Certificate of Coverage (COC). The SOB is usually a document (2 to 5 pages) that summarizes your coverage, cost-sharing obligations, and deductibles. An EOB describes in detail your benefits for a particular service or visit to a health care provider. The COC is evidence of your primary contract for health insurance. The COC may include the policy itself, which typically runs from 50 to 100 pages in length. The policy provides tremendous detail about your plan, what is and isn’t covered, appeal rights, definitions, and more. You can usually get a copy of both documents under the “My Benefits” tab of your insurance website.
If you can’t find the COC online, contact your health insurance company and ask for it. Sometimes it’s referred to as the “full insurance policy.” It’s best to make this request in writing so you have proof that you did so. If you still can’t get a copy of your COC, then you can file a complaint (see “Handling errors and appeals,” below). Once you get a copy of your COC, save it to your computer with the date. Policies often change on every year, so you want to make sure that you always have a copy of the policy that was active when you received treatment. Read through your COC and pay special attention to the following:
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Type of plan (HMO, PPO, High Deductible)
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ERISA or non-ERISA plan
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Governed by state or federal law
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Your cost sharing, deductibles, and out-of-pocket maximums
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Policy exclusions
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Appeal rights
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Pharmacy benefits
ERISA stands for the Employee Retirement Income Security Act of 1974. An ERISA plan is a health insurance plan that is provided by an employer.
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Organizing paper documents
Although you can opt out of receiving claims or correspondence through the mail from your health insurance company, it can be helpful to have the paper copies on hand to easily sort through. To keep all of the documents organized, you can:
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Set aside a special drawer or box for claims and prior authorizations. Review each paper so you can learn to identify if the document is just a general claim or if it’s correspondence that needs a response. Place the general claims into your dedicated drawer or box so you can go back to them if there’s an issue. If you created a login on your insurance website, you can also view all the claims online. Flag any documents that need to be responded to in a specific time frame and make sure you do not miss the deadline.
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Create a binder or folder for current correspondence and issues. This is where you can put mail related to actual correspondence or appeal responses you receive from your health insurance company. It helps to keep these separate from general claims.
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Set up a folder for general insurance info. Use this folder to store useful information that you need on a regular basis. Include a copy of your insurance card, claim forms, notebook paper, and mailing supplies for submitting any out-of-network claims to your health insurer. If you submitted a Health Insurance Portability and Accountability Act (HIPAA) authorization form to your insurer, which gives another individual permission to speak with your providers without your consent, keep a copy of the form in the folder as well. On the front of this folder, write the:
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Health insurance policy number
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Last 4 digits of the primary insurer’s social security number
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Pharmacy phone number
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Doctor’s phone number
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Health insurance company’s phone number
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Use the inside of your folder as a phone log or deadline tracker. If you speak with someone at your health insurance company, write down the contact’s name and the date you spoke. Keep any additional notes you take in the folder too.
Handling errors and appeals
If something on a claim or other correspondence doesn’t look right or you think there was an error, email a representative of your health insurer. Sometimes a claim just needs to be reprocessed. If you aren’t satisfied with the response or your claim was denied, your next step is to submit an appeal. How to submit an appeal will always be included on the bottom of your EOB or in your COC. Always send your appeal via trackable mail and save a copy with the delivery service’s tracking number.
If your policy is not covering something that you and your doctor think should be covered or your health insurer is not responding to your appeal, don’t give up. There are organizations and resources that allow you to file complaints electronically and can help you resolve problems with your health insurer:
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Department of Labor: Employee Benefits Security Administration
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National Association of Insurance Departments: Local Department of Insurance
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Centers for Medicare & Medicaid Services: Consumer Assistance Program
You can also try posting your complaint on your health insurer’s social media sites or contacting your local media.