In our practice, we have observed that claim reviews performed by insurers, employers, and other claim administrators, are frequently flawed by some of the same recurring inadequacies.  Policyholders and plan participants should be aware that these practices may provide strong arguments for overturning a denial of benefits:

• Failing to counter a treating physician’s opinion with an equally, or better qualified,  ­health care professional.  Where a patient’s claim involves multiple sclerosis, for example, and a neurologist has submitted a supporting opinion, a claim administrator cannot reasonably rely on the opinion of a claim examiner, nurse, or general practice physician -- all of whom lack the appropriate expertise to challenge the determination of a neurologist -- to deny a claim.
• Imposing requirements not found in the insurance policy or benefit plan.  Both insurance policies and benefit plans are viewed, legally, as contracts, and courts tend to enforce them according to their terms.  A claim administrator acts unreasonably when it denies coverage based on definitions and requirements not readily found in these contracts.
• Failing to provide a detailed explanation of the basis for a denial of coverage.  Claim administrators, in general, should not leave a policyholder or plan participant in the dark.  A denial letter should recite the applicable facts, relevant plan or policy provisions, and the reasoning that supports a denial.  Any letter lacking such detail suggests either sloppiness or a recognition that the denial is without substantial basis.  Anyone receiving such a letter should point out this deficiency and demand a more detailed explanation from the claim administrator. 
• Failing to investigate disputed issues or to request information needed to approve a claim.  In some cases, a claim administrator will determine that a claim is not supported by sufficient evidence, but makes no effort to identify or obtain evidence it would consider sufficient.  A policyholder or plan participant should demand that a claim administrator describe the evidence it requires to approve a claim and should endeavor to obtain that evidence if the claim administrator is unwilling or unable to do so. 
• Delaying payment of claims.  Unless awaiting new or additional evidence, a claim administrator should make a approve or deny coverage within a reasonable period of time.  State and federal law, as well as the terms of the policy or plan, itself, will usually prescribe the amount of time permitted.  Regular, courteous follow-up with claim personnel to check on the status of a claim, to offer assistance in procuring medical records and other proof of claim, and to give reminders of pending deadlines, is helpful to make sure a  claim is processed in a timely fashion and is not overlooked.  If phone calls are not returned, or a decision is not reached within the time frames set forth in the insurance policy or plan, a claimant should consider “kicking it up a notch” by enlisting an attorney, a political representative, or the Consumers’ Division of the Insurance Department, to intervene in your behalf.