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What to do in the event a Florida health insurance company denies a claim or god forbid, rescinds your coverage.

In some instances insurers can't void your coverage unless someone can demonstrate it was your intent to deceive them. In other instances they can drop you over any inaccuracy, even an innocent mistake such as misstating your health and weight even though it was only slightly off.

1. Don’t assume that the first “no” you receive is final.
About 10 percent of all Florida health insurance claims are unjustly denied but less than 1 percent of people making insurance claims even question when their claim is denied. The majority of policyholders who do contest their cases either win their cases or improve their settlements....70% according to most sources.

2. Insist on a written explanation from any Florida health insurance carrier.
Florida health insurance laws require insurance companies to provide written explanations of claim denials. Failure to comply may constitute an illegal practice by the insurer.

3. Read your policy carefully to determine if the claim was legitimately denied.
The insurance company may have interpreted a clause in your policy differently from the way you understand it. Respect your sense of fairness and what you expect the policy to cover. If the ruling doesn’t sound fair, there’s a good chance that it isn’t.

4. Do not accept filing errors as ground for refusal.
Always follow your insurer’s instruction for filing a claim. But if you fail to fill out a form correctly, or if you miss a deadline for submitting a claim – even if you are months late – an insurance company cannot refuse to pay an otherwise valid claim unless the company can show it has been harmed by your error or prevented from making an adequate investigation due to your delay.

5. Do your own research to support your claim.
If your insurance pays less than you expected for care provided, check what other doctors in your area charge for the same care. If other doctors charge more than you received, challenge the payment.

6. Ask your health insurance agent or group policy administrator at work for support.
The agent from whom you purchased your insurance has a duty to make sure the coverage protects your interests.

7. Contact the insurance company directly.
If your insurance agent or claims administrator doesn’t resolve the problem within 30 days, telephone the insurance company yourself. Be polite but persistent, and keep going up the corporate ladder. Be sure to make a record of all phone calls, including the names and positions of everyone with whom you speak. Save your phone bills that list the calls. Follow up each call with a brief letter stating your understanding of the conservations, and requesting a response within 30 days.

8. Complain in writing if your phone calls don’t work.
Begin with the person who denied your claim, then write to the person’s supervisor. Include your policy number, copies of all relevant forms, bills, and supporting documents and a clear, concise description of the problem. Request that the insurer responds in writing within three weeks. Keep copies of all correspondence. Send letters by registered mail. Explain what negative effects the denial of your claim is having. Use a courteous, unemotional tone and avoid rude or blaming statements.

9. Write a follow-up letter to the Florida health insurance company.
If you receive no response, send follow-up letters, with your original letter attached to the insurance company’s consumer complaints or customer service department and to the company president. In most states, failure to respond promptly to letters regarding claims is an unfair insurance practice.

10. Enlist outside help.
If necessary, add pressure from:

• Florida Department of Health Insurance – this is free. 

• A professional arbitrator.

• A lawyer.

Thanks for visiting this Florida health insurance webpage and feel free to call if we can help you with any questions concerning your health insurance coverage.