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Patient Advocate Foundation
help@patientadvocate.org
Phone: (800) 532-5274
Fax: (757) 873-8999
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When to Consult an Attorney

This is an important question and one that is asked frequently. There is no right or wrong answer. Many people feel more secure discussing their case with an attorney when they receive the denial. Others would rather appeal the decision on their own to see if they can overturn it without legal help and expense. For some it depends on the cost of the procedure which has been denied. It may make more sense to seek legal advise if the procedure costs $100,000 than if the procedure costs $1000. As previously mentioned, if you do not understand the appeal process or you are unable to get answers from your employer or insurance company, an attorney may be helpful to advise you of your rights and options. This is an individual decision. If you decide to seek legal advice you should consider the following:
  • Select an attorney with experience in healthcare law.
  • Discuss the legal fees up front and request a detailed billing.
  • Determine at what point the attorney will take over the case.
Some patients will completely exhaust the administrative appeal process before they ask an attorney to take over the case. It is imperative that you make every effort to have an attorney involved in the case throughout the administrative appeal process in the event you wish to pursue the case later in court.

Others to Notify
Insurance and patient's rights are a hotly debated political issue. Patient's often ask if it is helpful to notify their state and local representatives of their insurance issues. In some cases it has been helpful. Other times patients get nothing more in return than a form letter stating there is nothing their legislator can do. You may choose to approach this question by asking yourself, "What do I have to lose?" You are already preparing your own appeal letter. You could easily send a copy of your denial letter and your appeal letter to your legislators asking for any assistance they can provide.

It may also be beneficial to notify your State Department of Insurance. The duties of the insurance commissioner and the Department of Insurance vary from state to state. One of the main objectives is to be sure the insurance company is following the patient's policy. The Department of Insurance may also be aware of any state laws that may come in to play in a specific case. Many states require that problems be reported by the patient in writing and may even require that their forms be filled out. It can be helpful to notify the Department of Insurance in your state when you receive the original denial. You can call them to request a copy of the necessary paperwork to submit your complaint.

In some rare instances it may be necessary to contact the media. This is recommended only if you have tried at length to resolve the problem and have enlisted the help of your legislators and the Department of Insurance with no resolution.

Expedited Review
If you have received a denial for a procedure that must be performed within a specific time frame, you and your doctor need to communicate that to the insurance company immediately. Most states have laws protecting patients in an emergency. That may be different if the procedure must be started in near future. Most insurance companies already have a plan in place for such occurrences and their guidelines will be different. If you do not feel that you are making progress toward your goal and time is short, you may choose to consult an attorney to advise you of your rights and options.

When to Contact the Patient Advocate Foundation
You may contact PAF at any point in the process for our advice, guidance, and support. The appeals process is very complicated. It requires you to gather information and write letters. You need to keep a notebook and a file for documentation. You need to remain courteous and polite when working with your insurance company, while you are dealing with the stress of an illness. You now know what steps to take to appeal your denial. Take this process one step at a time.

Take it one day at a time. The PAF would be happy to answer any questions you may have. To reach the Patient Advocate Foundation:

421 Butler Farm Road
Hampton, VA 23666
Phone: 1.800.532.5274 -or- 757.873.6668
Fax: 757.873.8999
Email: help@patientadvocate.org
INTERNET: www.patientadvocate.org

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