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Health Insurance Claims Help

Page Contents...
-- Get A Form
-- File A Claim
-- Dispute A Claim
-- Accident Claim

Get A Form

Florida law standardizes the claim forms used for health insurance.

Claim forms are available from your insurance provider and are normally provided with your policy. Also, many doctor's offices and hospitals keep claim forms on hand. 

File A Claim

Notify your insurance company as soon as practical from the date of your illness or injury. Most insurance contracts require that your claim be filed within 90 days (or less) of first diagnosis or treatment.

When completing the claim form, be sure your personal information and policy number are clear and readable. Be sure the form is signed and dated.

Attach your original medical bill. Generally, this bill will contain all the information that your insurance company needs. Usually, there's no need for your doctor to complete any portion of the claim form. Keep copies of everything.

Upon receiving your claim, the insurance company should promptly send you a written notice verifying receipt. You may be asked for additional information about your health history, such as "the full names of all doctors seen and medications taken during the past three years". When this occurs, the company is making sure that your claim is not related to a "pre-existing condition" (see your policy for definition).

Don't be intimidated if you don't have all the information at your fingertips. Our Check Doctors page may help you find your doctor's full name and address. Many people won't remember every medication taken during the past three years. Do the best you can. If you can't remember the exact name of a medication, say so and give a description such as "antibiotic" or "pain medication".

Respond promptly and keep copies. Be sure that your name and policy number are clearly printed on all correspondence.

Dispute A Claim

Your insurance company should respond to your claim promptly after all requested information is received. The company should provide an explanation if it rejects all or part of your claim.

Do not hesitate to dispute a claim if you feel it was not paid properly. Mistakes can happen. Normally, you have up to 60 days to dispute a claim. However, if you intend on doing so, you should pursue your cause as soon as possible.

First, read carefully the reason given for denying your claim. Then check your policy carefully to be sure that your claim is a covered expense.

People are sometimes confused about the following provisions of their health insurance policies:

• Routine physical or wellness exam - often not covered.
• Emergency room visit - was it a true medical emergency?
• Exactly what the doctor's office co-payment covers.
• Failing to respond to a request for information.

If you have any questions about your coverage, you should contact your agent or the company or both. In extreme instances, legal counsel may be a consideration.

If you are confident your dispute is valid, read the section of your policy on disputes or grievances and note carefully the procedures. We recommend that you notify the company of your dispute by certified mail - return receipt requested. Although your health insurance agent may guide you, the notice of dispute must come directly from you the insured. Also, assistance is available from the Florida Department of Insurance (see Top FL Health Links.)

Many disputes are due to lack of communication, a misunderstanding, or clerical error and are quickly resolved. Yet, situations often occur where resolve and determination is called for and ultimately pays off for the consumer.

In a serious dispute, remember to be methodical, use certified mail, and keep copies of all correspondence.

Help Speed Up An Accident Claim

If your claim is due to an accidental injury and over a certain amount (normally $200 or more), you will be asked to furnish complete details of the event.

If you provide this information at the time of your initial claim (use a separate sheet of paper, signed and dated), it may speed up the claim process by a few weeks. Typically, your insurance carrier will ask for the following information.

1. How did the injury occur? (Give details.)
2. Where did the injury occur? (Be specific.)
3. Date and time of day (a.m. or p.m.) that injury occurred
4. Was the injury due to a motor vehicle accident? If yes, send a copy of the police accident report.
5. Was the injury related to your occupation? If so, answer the following: What is the nature of your occupation? Are you self-employed? Do you have workers compensation. If not, explain why not.
6. Was the injury the result of another party's negligence or did it occur on another party's property? If yes, explain in detail.

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