Making Sure Your Insurance Company Pays Up

Just ask Tim and Denise F., who opted to spend more than the cost of a basic policy, thinking that they were providing the best possible coverage for their children. When 3-year-old Allison had recurrent ear infections, their pediatrician recommended she have tubes put in her ears, or possibly face permanent hearing loss.

“We were shocked to learn that our company wouldn’t pay for it,” says Tim. “To fight them would have taken weeks, or even months. We didn’t want Allison to have to wait. So we dipped into our savings and paid for it ourselves.”

It’s estimated that about only one-third of health insurance claims filed are ever fully reimbursed to the client. When an insurance company denies a charge, or pays less than the full amount, they must tell you exactly why. This is communicated to you in an “Explanation of Benefits,” or “EOB.” This is typically a one or two-page document in which the insurance company lists what was paid and to whom. Or, it may list what the insurance company is refusing to pay, in which case it must explain why not.

Sometimes this explanation is written in a sentence or phrase, such as “over and above reasonable and customary charges” or “not covered by policy.” In many cases, however, the insurance company merely lists a code with an asterisk. You then have to search the EOB to find the code’s interpretation. (They don’t make it easy!) The code might read something like: Code OA – Over and Above Reasonable Charges, or Code UT – Unnecessary Treatment.