Filing an insurance claim is often directly preceded by a
traumatic event in your life. So the last thing you need is a fight
with your insurance company to force it to pay. But you can take
steps at every point in the process -- and even before a traumatic
event occurs -- to help make sure you get satisfaction.
Are You Covered?
Says Angelyn Treutel, an independent insurance agent in Bay St.
Louis, Miss.: "People who do some planning are going to get through
the claims process most easily." She has plenty of experience with
tricky claims: In 2005, Hurricane Katrina's storm surge engulfed
her town and left her house in 12 feet of water. It was about a
year and a half before Treutel could move back into her home, and
at the same time she was helping clients get their claims paid,
Technology has helped smooth the claims process since then, says
Treutel. Smart-phone cameras, insurers' apps, Web tools and other
resources can help you prepare before a claim, submit information
and gather evidence to support your case if your claim is
Even if you take preventive measures plus steps to file a
hassle-free claim, you could find yourself losing a tug of war with
your health, homeowners or auto insurer over how much it will pay.
These tactics will help you fight back.
Health insurance claims earn the title of most complicated
because you must deal with the complex relationship between your
health care provider and your insurer. It doesn't help that doctors
and hospitals provide different deals for each insurer.
You'll avoid many hassles if you know what your policy does and
doesn't cover -- and what it requires. For example, do you need to
get preapproval to go to certain facilities? "You don't want to
wake up in the middle of the night with severe abdominal pains
wondering if you'll be covered in the ER automatically or if you
have to notify your insurance company first," says Tom Bridenstine,
Virginia's managed-care ombudsman, who helps people with claims
questions and assists in appeals.
Also, find out how much your out-of-pocket costs will be for an
out-of-network provider. Charges for such visits are a common
source of complaints because the co-payments as well as the total
cost may be higher than with in-network providers. And the claims
process may not go as smoothly because the out-of-network provider
hasn't set up an electronic claims link with the insurer, says
Ingrid Lindberg, of health insurer Cigna.
If you have questions about coverage for out-of-network care,
call your insurer and "note the date and time, the person you spoke
with and a brief summary of the conversation," says Bridenstine.
"I've seen that kind of detail help win many appeals if the rep
from the insurance company inadvertently gave the wrong
When you have a claim, compare the form you get from the doctor
(called an encounter form) and the doctor's bill with the insurer's
explanation of benefits (EOB). "Never pay a doctor's bill until you
get your EOB," says Pat Pane, a medical claims specialist in
Wilmington, N.C. The doctor's office may have sent you the bill
before filing the claim with the insurer.
How to fight back:
A denied claim could just be an administrative problem. The insurer
may need more information from the doctor, or wrong codes may have
been entered somewhere along the paperwork trail. If addressing
those items doesn't solve the problem, don't waste your time with
"repeated phone calls over weeks and months," says Bridenstine. "Go
into the official appeal process." That forces the insurer to
respond in a timely manner. The denial letter usually outlines the
Call your state insurance department for guidance before you
file an appeal (find a
link to your state's
), especially if the claim is for a large sum of money. Be prepared
to provide evidence from your doctors about why the procedure was
medically necessary or why you needed to go out of network for
care. If you aren't happy with the results of an internal appeal,
your state may offer an external appeals process with third-party
Sometimes you need to provide extra paperwork if you have
trouble getting some of the claim paid. Bridenstine recently helped
a Staunton, Va., man file an appeal contesting a $37,013 bill he
got from Mayo Clinic for prostate cancer surgery -- in addition to
the $2,246 he paid for his deductible and co-payments -- after he
had contacted his insurer for permission to go out of network for
the care. The patient worked with Bridenstine to file an appeal
with his insurance company. The appeal included information from
his doctors justifying the medical need to go out of network, and
his balance due was lowered to $437.
You can get extra help from a claims specialist. These
professionals can help organize your claims paperwork, deal with
the insurer, spot errors, collect extra documents from doctors, and
help you file an appeal. Find one at
. Expect to pay about $130 to $150 per hour.
Insurers used to recommend making long lists of every item in
your house and storing the records in a safe-deposit box. Now you
can take a video of everything -- including your possessions and
architectural details-with your smart phone and e-mail it to
yourself. The Insurance Information Institute's home inventory app
) and the app from the
National Association of Insurance Commissioners
make it easy to save the information.
When you have a claim, gather as much information as you can as
soon as possible. "Make sure you're not putting yourself in danger,
but take as many pictures as possible and take notes," says Derek
Ross, an independent insurance agent in Tarzana, Cal. In traumatic
situations, it can be difficult to recall all the information
It helps to photograph the source of the damage, such as the
source of a water leak, says Patrick Gee, senior vice-president of
personal claims for Travelers. "Then there are many fewer questions
about the cause of the loss." Do what you need to do to prevent
further damage, such as boarding up broken windows, but don't start
cleanup or other significant work until the insurance adjuster
Filing a small claim could cost you a claims-free discount or
trigger a rate increase, and filing a series of small claims could
eventually get you dropped by your insurer. It's better to pay
small claims yourself and keep your deductibles high to benefit
from lower premiums.
Use apps from your insurer that make it easy to send pictures
and other records. Then keep in touch with your adjuster, either
through e-mail or by phone. "Follow up once a week or so to find
out if there's anything else you should do," says Treutel.
Set up a meeting with the contractor and the adjuster at the
damage site. "It's good to evaluate the damage from the same
perspective," says Gee. If you don't have a regular contractor --
or if you have water damage or other special issues -- your insurer
may be able to recommend some companies.
Keep receipts for hotel stays, meals and other extra living
expenses while you're out of your house; those costs may be
reimbursed by the insurer. Also keep records of all supplies you
buy to help contain the damage.
Contact the insurer if the contractor finds new issues after the
repairs begin. "We might take a look at it again, and that's a
normal part of the process," says Gee.
How to fight back:
Every state insurance department has a free service to help you
through the claims process and to make sure you're getting
everything you're entitled to under your policy, says John Huff,
Missouri's director of insurance. Huff says that, mostly due to the
devastating tornado in Joplin, Mo., his department had 21,000
inquiries last year and recovered an extra $19 million in claims
payments for consumers. If your area has had a major disaster, your
state insurance department may set up a special appeals
Your state can help even when there's no major disaster. "It's
amazing how quickly many claims get paid once you contact us," says
Monica Lindeen, Montana's commissioner of securities and insurance.
"And sometimes just threatening to contact us can help."
Don't jump at an offer from an independent adjuster to provide
extra help before working with your insurance company and state
insurance department. Freelance adjusters charge a percentage of
your payout -- typically 10% to 15% of the amount recovered. In
Joplin, as well as areas affected by Hurricane Katrina, some public
adjusters showed up right after the storm and tried to get people
to sign on with them before going through the claims process with
their insurer. If you decide to use a public adjuster, be sure he
or she is licensed with your state insurance department.
When you're in an accident, don't just exchange insurance and
contact information with the other driver. Take pictures of
everything with your phone's camera -- your car's damage, damage to
the other car, the accident scene, and the other driver's license
plate, registration and insurance card. Get contact information
from any witnesses. Then contact your insurer or agent.
Some insurers, such as Chubb and Travelers, have apps that walk
you through the claims process and let you upload the photos and an
audio or written description directly to your claims file.
Travelers' Auto Accident Help app
produces a detailed accident report that you can send to any e-mail
address. If the police arrive and write up an accident report, get
the report number.
You can generally use any repair shop to get your car fixed, but
taking your car to a repair facility on the insurer's recommended
list may expedite your claim. Some insurers have special one-stop
claims facilities where you can take your car, meet a claims
representative and arrange for a rental car.
How to fight back:
If your body shop says it will cost more to fix the car than the
insurance appraiser says, provide a detailed estimate from the shop
to the insurer. Sometimes the difference can be a result of policy
specifics -- if, for example, your insurance covers after-market
parts but the body shop wants to use original manufacturer's parts.
You may also have the right to get an "independent appraisal" --
you get an appraisal yourself and a third party weighs that along
with the insurer's appraisal and settles on the number. (This is
usually called the "appraisal clause" in the policy.)
If the insurer says your car is totaled -- because it will cost
significantly more to repair your vehicle than it's worth -- and
you disagree on the value it has assigned, make a case for why your
car is worth more. Compare the selling prices of used cars the same
age and in similar condition in your area (you can see local ads at
Autotrader.com) and check used-car values at Edmunds.com and
It can also help to get your agent involved; sometimes he or she
can help speed the claim along or ask for specific information from
the insurer about why the payout was lower than expected. If the
claim payment is still too low, enlist the help of your state