Tips for Getting Help from Your Health Insurance Company's Customer Service Department

In order to be competitive, a private health insurance company has to cater to the needs of hundreds of employer groups, unions and individual consumers, so they sell hundreds of different policies. The people you talk to at the insurance company have to answer questions about all those policies, but there are too many options, benefit packages, and administrative rules for anyone to be an expert on all of them.

Combine this extravagant excess of possibilities with the company's need to watch the bottom line, and you get customer service representatives who can't possibly know all the answers.

The most important advice I can give you is to read your benefit booklet. If you aren't sure if a service will be covered, call the number on the back of your card before your appointment to find out. Write down the answer you're given, even if the representative tells you the medical service is covered by your contract. If you call up the insurance company in advance of an appointment, and they tell you that a service will be covered, but the claim is not paid because the customer service rep made a mistake, you may be able to get the claim paid on a special exception basis. They don't have to do this - you are responsible for knowing what is in your contract - but many companies do this as a matter of good faith. To prove you were given bad info, you'll need the date and time of your call so they can listen to the recording. For this reason, always make notes when you call your insurance company.

If the company says the service isn't covered, but you need it anyway, you may need to go ahead with the appointment and accept the financial responsibility for it.

Remember - health insurance companies don't manage care. They manage contracts. So know your contract. The insurance company's customer service representatives need to know 50 or more contracts. You only have to know one.

Let's assume that you read your benefit booklet, and you don't think a claim was paid the way it should have been. If you called the health insurance carrier and you were told that there was nothing they could do about it, it's possible that:

1. The insurance company is right, and your claim was paid in accordance with your contract. To find out, dig up your benefit booklet one more time and check. The customer service rep should be able to tell you on what page of your booklet the benefit is discussed. If you don't have a benefit booklet, they should be able to tell you how to find it on their website, or mail you one. If they sound rushed, try to ignore it, and take as much time as it takes to understand why the claim was paid the way it was.

2. Or - the customer service representative is new to her job, confused about this particular benefit, or in too much of a hurry to go beyond the basics. Have her explain her reasoning, and tell you where her answer is documented.

3. Or - the customer service representative can see on her computer screen that you have called before, and he or she is giving you the answer that the previous representative wrote in your file. There is a possibility that this answer is right, but it is entirely possible for two or more people to get it wrong. Again, any answer you receive should be documented in your benefit booklet - they don't get to make it up.

4. Or - the customer service representative could be following the documentation she's been given, but the documentation is wrong. Your author spent several years writing documentation for a health insurance company, so I know they sometimes make mistakes. If you get one claim fixed, but the next one gets paid the wrong way again, you may need to make repeated calls to the company to fix them. When this happens it could be a sign that their computer claims processing system is programmed incorrectly and they don't have the resources to get it fixed, or they are not training their claims processors correctly. (If this happens to you a lot, and you have a group policy, give your group administrator or HR department a call. They have more clout than you do. Or contact your state's Insurance Commissioner.)

If you really aren't satisfied with the way a claim was paid and the customer service reps can't fix it, there are some things you can do. The first thing you would do is make another call and speak to another representative. Be sure to call when you are in a calm and empathetic mood. We don't want to admit it, but even the most professional customer service representative, of any industry, is put on the defensive when you call up mad - even when you have every right to be. To get the best service, try to stay calm.

Also remember that you have the right to simply call up and ask for a supervisor. If the person who answers hesitates, let them know that you've already spoken to a number of people on her level and you need to take the problem to someone who has more clout. Make this request at the beginning of your call, so the rep doesn't feel that you're questioning her judgment. If the supervisor tells you the company is right, make sure she tells you why, and where you can find documentation that supports her answer. (Supervisors actually know less about the benefits than the regular people on the phone, but they can be a great resource, and they do have the power to get things done.)

If you still don't feel the problem is solved, you may be able to file a complaint. If this is allowed on your policy, ask the customer service representative to mail you the form. If you decide to do this, approach it like a small court case, and get as much evidence on your side as you can before mailing it in. If you find a paragraph in your benefit booklet that backs you up, so much the better. However, if you are trying to have a claim paid for a service that is excluded from your contract, no appeal will change the outcome, so make sure you have the contract on your side before taking the trouble to file a complaint.

If you don't like the result of the first complaint, and you still think the contract covers the service, file an appeal if your company allows it. This usually takes the issue outside the customer service department and may even take it out of the company to a separate panel, which may have appointed representatives that are acting for the state. In all cases where large sums of money is involved, a call to a qualified attorney would be a good idea.

And last - you may also be able to file a complaint with your state's Insurance Division. The complaint and appeal process, and your state's Insurance Division address, should be printed in your benefit booklet or on the health insurance company's website.