Colorectal Cancer News

New Rules Make it Easier for Public to Appeal Denials of Health Insurance Claims

Patients will find it easier to appeal the denials of health insurance claims under rules issued July 22nd by the Obama administration. The regulations guarantee consumers the right to appeal denials -- directly to their insurers and then, if necessary, to external review boards.

The external-review requirement will apply, for the first time, to companies that are self-insured -- ones that pay their employees' claims directly rather than buying insurance to cover their workers. Most states already guarantee consumers the right to external appeals, though their rules vary widely.

However, the rules don't apply to "grandfathered" plans -- those that existed on March 23rd, when the health law was enacted. Plans can lose their "grandfathered" status if they make significant changes to their plans regarding costs or benefits. Still, by next year, an estimated 31 million people in employer-sponsored plans and 10 million more in individual plans will benefit from the new appeals rights, according to the White House.

Advocates hope the changes will give consumers a fairer shot at fighting back when their claims are denied. Insurers deny claims for many reasons: They may determine that a treatment is not medically necessary, for example, or that it's experimental. Sometimes denials relate to coverage of pre-existing health conditions.

But appealing insurers' denials is easier in some states than others. Many consumers don't know that they can appeal. "Not enough consumers know this is an option that they have," said Angel Robinson, a consumer advocate in the Iowa Insurance Division. 

The new regulations take effect for plan years starting Sept. 23. But they won't automatically apply to residents in states that have existing external review laws until next July. That's to give states time to adjust to the new standards. If states fail to change their rules by next July, their residents will then be able to rely on the federal standards.

Reference
Phil Galewitz and Michelle Andrews. New Rules Make it Easier for Public to Appeal Denials of Health Insurance Claims. Kaiser Health News. July 22, 2010.

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