Insurance Woes

By Rachel Teicher & Lisa Kantor, Esq. – Kantor & Kantor, LLP

At long last, you decided to reach out for help. To make a change. To take a leap. You’re ready to seek treatment for your eating disorder.

Yet even this seemingly simple first step can be a daunting task for many, requiring great bravery in the midst of a disease that thrives on keeping people weak. Contemplating the idea of life in a new form, free from the disease, can be incredibly uncomfortable and overwhelming – intolerable maybe. Thoughts of unpleasant changes and persistent challenges linger, but the curiosity and longing for change encourages you. And so you begin your search for treatment.

And then you discover one of the most disturbing barriers to eating disorder recovery: the insurance denial. Almost as fervently as you committed yourself to seeking treatment and embarking upon your recovery journey, your insurance company (almost certainly not a qualified doctor, therapist, or eating disorder expert) decides that treatment is not for you. They decide that treatment is not medically necessary; that the appropriate level of treatment for you is not covered under your plan; that the treatment detrimental to your health and survival is not essential.

Twice the battle! In addition to fighting a disease, you must now go to battle with your insurance company (over the seemingly obvious reality) to convince them that treatment is critical. It isn’t fair, but it happens all the time, every day.

Many people are unsure of what to do when an insurance denial arises. We can help. We understand that when your insurance company denies access to health benefits, it only intensifies an already distressing situation.

At Kantor & Kantor, we spend every working day disputing insurance denials, educating insurance companies about the severity of the illness, and fighting so that those struggling with eating disorders have access to the life-saving treatment to which they are entitled. We have prepared a few important guidelines to assist you during what is often a hectic time. Keep these steps in mind when beginning your recovery journey. If your health claim is denied, following these simple guidelines will make it much easier to get your benefits recovered…and that means having access to treatment and the chance for recovery.

Once your claim has been denied by your insurance company (and you have an actual denial in writing), contact Kantor & Kantor for help. You can call us for a no-cost consultation at (800) 446-7529. Remember that we work on a contingency fee basis, which means you do not pay us a fee unless we get your claim paid.
In order for us to help you, you must receive treatment and stay in treatment, even after a denial of benefits. You must be able to STAY in treatment. We understand that treatment is extremely costly. When your insurance company denies coverage, this can become an even more stressful time focused on financial burden rather than recovery and treatment. In order for you to focus on recovery, we advise following your treatment providers’ recommendations for treatment protocol, level of care, and length of treatment. Let us work with your insurance company to help with that part of your journey. We will seek reimbursement of the benefits available under your policy. In order for us to seek reimbursement, the law requires proof of an outstanding bill or payment for the treatment.
Under ERISA (Employee Retirement Income Security Act), you have the right to file a lawsuit to recover unpaid benefits. If you do not have unpaid benefits, there is no ERISA claim. If you have been denied benefits by your insurance company for treatment, but leave treatment without paying anything out of pocket, you do not have unpaid benefits. We encourage clients to seek proper treatment based on their treatment providers’ recommendations, not the treatment dictated by the insurance company.
Know your policy/plan! Request a copy from your employer or the insurance company and become familiar with it. They are required to give you a complete copy upon your request. Every plan has its own rules and timing limitations with regard to submitting appeals and filing a lawsuit. Each plan and every state has its own requirement as to how long you have to act. We have encountered statute of limitations from as little as 30 days to as long as four years. Don’t let this prevent you from pursuing an appeal or litigation.
Use these tools to advocate for insurance coverage, and please do not hesitate to call us with questions.

We understand, and we can help.

www.kantorlaw.net (800) 446-7529