How to Arbitrate With Health Insurance Companies

Health insurance companies may use arbitration as a dispute resolution process in place of the court of law. Arbitration involves the health plan, the health plan member and the arbitrator, who is an impartial third party. The arbitrator listens to both sides, reviews information about the dispute and makes a binding decision, which cannot be appealed or taken further in a lawsuit. Not all health plans use arbitration so check the details of your coverage carefully to determine your options. If the dispute involves denial of care, you may need to exhaust all levels of internal appeal within the health insurance company before proceeding to arbitration.

Instructions

1. Collect all written documentation of your dispute including medical records, correspondence with the health insurance company, doctor, hospital and witness statements. Consider having any doctor, hospital employee and witness statements notarized for added authority.

2. Contact your Human Resources (HR) department to advocate on your behalf. If your HR department supports your stance, with your permission they may contact your company's insurance broker who can contact the insurance company on your behalf to discuss your case. In addition, some companies retain the right to override the insurance company's final determination of care if your dispute involves a medical decision.

3. Retain an attorney who specializes in malpractice and health insurance litigation if your HR department cannot resolve the issue. An attorney may be aware of state or federal laws that protect your privacy and safety or that mandate certain health plan coverage that could affect your dispute. An attorney will help with the research, advise you on how to proceed and attend the arbitration meeting with you.

4. Contact experts, such as doctors, who can support your position and ask if they will provide testimony at your arbitration meeting with the health insurance company. It is your responsibility, as the insured, to provide opposition to the health plan's position. An expert can lend credibility and help show burden of proof to your claim.

5. Attend the arbitration meeting and bring supporting documentation, witnesses and experts with you. If you are not present, depending on the rules of your health plan and the state of jurisdiction, failure to appear may render an instant decision in favor of the health insurance company.

References

• Mediate: Medical Malpractice Disputes in the Age of Managed Care
• State of California; Department of Managed Health Care: Arbitration Decisions