Your Health Plan: How to Fight Back

More consumers seem to be getting fed up with their health plans’ coverage decisions—the rate at which they appealed insurers’ rejections rose by 34 percent between 2000 and 2006, the most recent year tracked. Here are some of the strategies patients can pursue:

Patients who write insurers to appeal are more likely to succeed if they pack the letter with references to medical research. Some advocacy groups like the Pulmonary Hypertension Association offer helpful letter templates for common denials.

An extra, concurring opinion adds heft to the patient’s argument, experts say. Prestige matters: Philadelphia attorney Mark Gallant says he had success overturning a friend’s optical-scan denial when he recruited a top doctor in the field to speak on the friend’s behalf.

When appeals reach a second round, the aggrieved often get to talk on the phone or meet in person with a medical director. But the conferences can last as little as 10 to 15 minutes. And “yelling and screaming,” says Karen Mariner of the National Multiple Sclerosis Society, “just eats up time.”

Larry Gelb, CEO of the advocacy firm CareCounsel, says many employers still have outdated or poorly written contracts with insurers, which can “open doors” in appeals. Copies of the contracts should be available in an employer’s benefits office.