If I were able to give only two tips, it would be:
- “record all expenses” and
- demonstrate your eligibility.
The second is reflected in the following true story.
In amongst a host of atypical experiences, my child is missing some teeth. They didn’t develop in utero. As a result, he requires some orthodontic care. Even though bones are part of the body, they are often not covered in our “free medical” system. I am responsible for a bill of $9000…unless my obscure insurance plan will cover it.
We were almost damned before we started. The orthodontic office said, “We’ll submit some documents and hope the insurer offers to cover it. In similar situations in the past, they haven’t. They have a policy, and a panel that looks at the file and makes a decision, period. None of us have any say.”
Whoa, Nellie. That’s not really how it goes. It actually goes like this:
- There is a law. A concrete, set-in-stone stipulation as to what circumstance is covered.
- Regardless of all office policies, and who is hired to look at the documents, the insurance department is required to honour the law.
- If the insurer disregards the law—or loosely interprets the law in their favour—the client may challenge the decision.
- If the client challenges it, the matter goes through an appeal process, and the client may well win the coverage.
I begged the orthodontic staff to submit nothing until I had had a chance to look up the law, precedents, etc. The more effectively your case is presented from the get-go, the higher the chance it wins at initial submission or appeal.
Alas, I was fairly certain the office wasn’t quite hearing what I was saying. The orthodontist staff remained certain that coverage was random, based in unidentifiable factors, a matter of fluke—like a lottery ticket! I feared the specialist would, then, proceed to submit documents without consideration of what information was actually relevant.
I cancelled my plans for the rest of the day, headed straight home, and began my work. Within four minutes, I had located the law that applies. Within another three minutes, I had located a very similar case that had gone to appeal and won. I supplied these to the specialist.
Now, there are things I cannot decide nor control:
- I do not control what the law currently is and states.
- As a non-doctor, I cannot know or declare that my kid’s skeleton does or does not meet the medical criteria.
- I cannot control what a third party does or does not bother to submit and when.
What I do know, however, is some administrative law. I have learned the process for applying for the coverage we are purported to have. I know what we are allowed to submit in this initial step. I know when the insurer must provide a decision by. I know how many days I have—after that decision is communicated—to initiate an appeal. I know what sources I may draw on to bolster our appeal.
In this case alone, such information has the potential of eliminating $9000 in out-of-pocket costs.
I may or may not win this coverage—that depends on whether my kid’s face does indeed meet the legal criteria. But given how many times I have won tens of thousands of dollars, taking these timely steps is well worth it to me. Even if I lose, it will have been excellent practice for our next pitch 🙂