What to do First if You’re Denied by Your HMO

Not unlike insurance, HMOs will frequently deny member claims and you may have to fight to get the compensation you deserve. Boynton Beach criminal defense lawyer and insurance expert Brian Gabriel has written a guide for the readers to follow should their claim or request for care ever be denied by their HMO.

When your treatment preference is discouraged:

  1. Is it really a denial?
    Discouraging your treatment preferences does not necessarily mean a flat denial

    2. Make a formal request.
    Return to the physician and say, “I’m making a formal request. Are you really denying me this?”
  2. Determine the basis for any denial of treatment.
    Ask the doctor whether the denial is medically or financially based.

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When you’ve been denied:

  1. Know Your Policy or Coverage Booklet.
    What coverage was purchased? Deleted? Which endorsements apply? What are the policy limits?

Make sure you have the entire policy or coverage booklet and all of the endorsements. Now read them. Increasingly, these documents are written in language an average person can follow. You will often find that your claim is covered under the policy for some reason which had not occurred to you. If you don’t have these documents, the company must provide them.

  1. Request an Explanation and Get it in Writing.
    Make the call. Some experts say that up to half of the claims initially rejected are paid upon review.

The Insurance Code requires that the company must give you the basis for the denial of your claim in writing. Demand that they do so and compare the reasons given with the policy or coverage booklet. Often the solution to your problem will become obvious at this point. Many errors are corrected at this stage by, for example, providing a letter from your doctor or other evidence which might cause the claims adjuster to change his or her mind. The company must provide you with any personal information, like lab tests or medical records, they relied on in denying your claim.

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  1. Document Your Claim.
    Good notes help you remember what was said, will aid anyone who tries to help you, and can be used to support your case in the event you need legal assistance.

Keep notes of each telephone conversation or other contact you have with the people working on your claim. Keep track of the date, time, identity, and title of each person involved. This will avoid having to tell the story twice, personalizes your case, and helps make sure you’re speaking with someone who has the power to help you. Always keep correspondence and put your communications in writing so the company cannot ignore you or pretend that you have not pressed your claim. If you are given an “opinion,” request that it be provided in writing. Follow up all oral contacts with the company with a letter (“As we discussed today…”). Send everything by certified mail: oftentimes the company will deny receiving information.

  1. Request a Review
    Ask if the reviewers are qualified to evaluate your particular kind of claim.

If you are a member of an HMO there will be a procedure in the Plan for a review or an appeal: make sure and request it. Find out if the review will be made internally or by an outside expert or panel. If you are covered by ERISA, make sure you comply with the appeal process. In other cases, request that the adjuster’s boss or supervisor review your claim. Sometimes problems are resolved at this stage.

  1. Get Help From Associated Parties
    From you employer. Your doctor. You insurance agent. A support/advocate group.

Your employer or your employees Personnel Department may be willing to help you by calling or writing the company. If the employer is the actual buyer of the coverage, the company will pay more attention to such a contact. If you bought your coverage through an insurance agent, they will often help you. Remember they are motivated to please you. Doctors can also be an important source of help. They will usually write a letter for you explaining why the claim should be covered, or why the company’s reason for denying the claim is incorrect.

  1. Appeal if required (ERISA)
    Comply with all appeal/dispute requirements in a timely manner.

You must punctually go through the appeal process set forth in your plan or you cannot bring suit against the insurer/carrier. Your case will be weakened, or even rejected entirely, if you do not comply with stated deadlines. Insist the insurer do the same.

  1. File a Complaint with the Regulators
    Policies covered by ERISA: U. S. Dept. of Labor, Pension & Welfare Benefits (202) 219-8211

If you are a member of an HMO, the only agency which may help you is the Department of Corporations. Insist on filing a written complaint. If you have traditional health insurance coverage, the Department of Insurance is often helpful. Again, insist on filing a written complaint. Companies will often offer to compromise if they get some pressure from the Department of Insurance. If your claim is an ERISA claim, the US. Department of Labor, Pension and Welfare Benefits Administration, has an investigative arm.


  1. State your questions/requests clearly and concisely; don’t allow a misunderstanding to come between you and what you want.
  2. Stick to the subject at hand; no one cares about what happened during your Aunt Tilly’s operation.
  3. Remain firm, don’t be intimidated. If your claim has been rejected, you have a right to find out why.