Has anyone successfully appealed a large health insurance denial?

[mamalatte]

We have a very high deductible health insurance policy, $15K deductible per person and $30K for the family. Of course, now that we actually have an expense that exceeds these amounts, it has been denied as not covered.

The expense is a $30K bill for residential inpatient mental health care for about one month for DH at a mental health / rehab facility. Has anyone ever successfully appealed a big item like this and does anyone have thoughts about whether it is better to hire a lawyer or try it on your own? I am fairly confident in our ability to do a decent job appealing, but apparently there maybe are lawyers out there who have a specialty of dealing with particular insurance companies, e.g., they specialize in Prudential, or whichever one, so I'm wondering if it would be smarter to seek out someone like that . . .

[frugalone]

For that kinda money, I think I'd at least consult an attorney. Get a free consultation, if possible. And I wish you the best of luck, no matter what you decide to do.

[Miss Cellane]

Don't forget that there are some insurance companies that simply deny certain claims the first time through. I've run into this several times for relatively low-cost, minor things. Every time I've appealed, the appeal has been approved.

You have nothing to lose and a lot to potentially gain by appealing.

[Simpler at Fifty]

Why was the claim denied? Were you aware during the stay it was not going to be covered? ie: Did anyone from the treatment facility sit down and tell you it was not going to be covered by your insurance? Did you call to ask if it would be covered? Look in your certificate to see if that type of stay is covered.

[Gardenarian]

I have appealed for smaller amounts, as my insurer, Kaiser Permanente, has not been good about telling me up-front how much my co-pay would be. In every case they have reduced the amount.
I would try a lawyer. I don't think it would cost you anything (except the percentage they take if you win.)

[mamalatte]

UPDATE: Realized that I somehow had not seen these replies, thank you for your thoughts.

Simpler @ 50: DH went to the inpatient facility at the recommendation of his psychiatrist, as psychiatrist (and DH) felt that he was at a high risk for suicide. We had been informed both by his dr. and also by the facility before/during the stay that it might not be covered, mostly because in their experience it is very hard to get coverage for mental health inpatient care. We were not able to get a firm coverage decision in advance. My summary of the denial in a nutshell is that DH was not suicidal *enough* to meet their standards. So, we did go into it with open eyes that it might not be covered, and I would not change that decision, given the life or death nature of the situation. But it's still infuriating to me, as the whole reason I pay for this policy, which covers basically nothing, is because I thought it would help in the event of just such a "catastrophe." It especially makes me mad because of the disparity in mental health vs. regular health care coverage. I can only thank my lucky stars that we actually had the savings/emergency fund to pay for it (and a lot of other related mental health expenses for DH and the rest of the family around the events). I understand how an experience like this could bankrupt a family.

We have not been able to find a lawyer willing to take the appeal; they seem to feel it is unlikely to succeed. We are pursuing it on our own anyway, can't hurt.

[Float On]

First off I sincerely hope the inpatient care was exactly what your DH needed and that he is having better days. Now with the billing you are probably thinking you might need a stay yourself (sorry for the humor). I'm sorry but I think every policy we've ever had had clauses regarding mental health not being covered. I'd still go ahead and try on your own. Keep supplying letters and documents from the Drs. It might help if your physician wrote something as well as the psychiatrist. If it's approached from a medical viewpoint would it make it any more coverable?

[bae]

Have you tried talking with the service providers? I've found they are often quite reasonable when you explain you aren't covered.

[mamalatte]

Float On - The policy does cover SOME mental health inpatient services but they just seem to have a very high threshold for determining whether the stay is "medically necessary." For example, there was suggestion that if DH had actually been actively trying to commit suicide at the outset of his stay or had already actually attempted, then stay may have been covered. Sigh. His psychiatrist is writing a letter. Since she is the one who has seen him regularly for years, I would hope they may give a lot of weight to her opinion on the necessity of the stay as opposed to the folks at the facility who were only meeting DH for the first time--it is their notes/impressions that the denial was based upon. DH also has a regular primary care doctor but had not seen that person around the time of the admission. Since the psychiatrist is an M.D. she is the one who handles all the meds, etc.

bae - service provider was clear that insurance may not pay and they expected payment in full anyway. they had payment plans but that was about the only accommodation.

[fidgiegirl]

I think there are new laws (not brand new, but relatively recent) about parity in mental health coverage. Again, maybe worth a visit to a lawyer.

[mamalatte]

Thanks, fidgiegirl. We have talked to several lawyers who handle similar things like Social Security disability denials, but these lawyers do not also handle health insurance appeals and weren't able to provide referrals for anyone who does. You are right about mental health parity laws -- our state does have one and it is one of the bases we would rely on for the appeal, along with additional evidence of the medical necessity of the care.