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New Rules on Appealing Rejections of Health Insurance Claims

Reporting from Washington — For many Americans, few experiences with the healthcare system are more frustrating than a rejected claim from an insurance plan. Rejection notices are often unclear, as are the procedures for challenging them.

On Thursday, the Obama administration issued new rules designed to simplify the process and expand consumers’ rights, as required by the recently enacted healthcare law. Here are some questions and answers about how the new protections will work.

Do Americans already have the right to appeal if a health plan denies coverage for something?

Many do, but rules differ depending on whether you get insurance from an employer or buy it on your own. Consumer protections also vary dramatically from state to state.

Existing federal rules require most employer-provided plans to have an internal process for appealing a rejected claim. But if you lose, there is no guarantee that you can take your appeal to an independent third-party reviewer.

You currently have no right to an external review of your denied claim if you work for a company that self-insures, as many large employers do. And if you buy insurance on your own, you may not get an external review either.

Thirteen states guarantee an external review for only some kinds of health plans. Six states do not require any independent review process.

So what happens now?

The new rules essentially standardize the process for internal and external appeals. Next year, if you qualify for the new protections, you will be guaranteed an internal review if your claim is denied, whether you get insurance from a private employer, a government employer or directly from a commercial carrier.

These internal reviews will have to conform to new standards that require health plans to explain denials more clearly, to speed decisions in urgent cases and to prevent conflicts of interest by arbiters reviewing denied claims.

In addition, people who qualify will be guaranteed an external review by someone not employed by their health plan.

States have until July 1, 2011, to put these external review regulations in place, or the federal government will do it.

Is everyone eligible for these new protections?

No. The rules apply only to health plans in which plan years begin after Sept. 23 and to existing health plans that make substantial changes, such as large increases in co-pays or employee contributions.

Existing health plans that do not make significant changes, which are called “grandfathered” plans, will not be subject to the new regulations.

Administration officials estimate that next year 41 million Americans will be in plans that must offer additional protections.

How do I find out whether I can get the new protections?

Consumers can check with their state insurance commissioner or with the Employee Benefits Security Administration at the Department of Labor. Benefits specialists can be reached by calling 866-444-3272.

The administration is making $30 million in grants available to states and U.S. territories to establish new consumer assistance offices or to bolster existing ones.

Will these rules make a difference?

It’s difficult to say. The Obama administration did not attempt to quantify the benefits of the new rules. But many consumer advocates — including Consumers Union, Families USA, the National Partnership for Women and Families and the AARP — believe they provide important new protections.

“Under these new rules, if your health insurance claim is denied, you’ve got a fairer shot at appealing the decision,” Consumers Union health reform campaign director DeAnn Friedholm said in a statement. “It’s another important step in building a healthcare system that truly works for consumers.”

BP Claims Process

BP has its claim site up and running…
“BP deeply regrets the spill that has occurred in the Gulf of Mexico as a result of the Deepwater Horizon Incident. BP takes full responsibility for responding to the Deepwater Horizon Incident

Key Claims Statistics – 22 July
Item Amount Percent
Total Claims 123,500 100%
Claims with at least one payment 34,500 28%
Awaiting Documentation for First Payment 53,500 43%
Having Contact Difficulty 11,700 10%
Withdrawn, Erroneous, or Duplicate 4,100 3%
In Process, Evaluating for Payment 19,700 16%
  • 77,300 checks written since May 3 (11 weeks)
  • 138,000 calls received
  • 22,800 claims submitted in the past two weeks
  • 18,100 claims submitted online (as of July 18)
  • 37 field offices, with translation capability at 9
  • 1500 member claims team
  • 5 day average time from “claim to paid” for individuals who have received checks
  • 9 day average time from “claim to paid” for commercial entities who have received checks

Items covered by claims

BP is committed to paying all legitimate claims for damages resulting from the oil spill and necessary response costs. This includes:

  • Property damage
  • Net loss of profits and earning capacity
  • Subsistence loss and natural resource damage
  • Removal and cleanup costs
  • Cost of increased public services
  • Net loss of government revenue

BP also will evaluate all claims for bodily injury even though they are not payable under the Oil Spill Pollution Act of 1990.

Individuals and businesses

BP has established a process for individuals and businesses to file claims to cover losses and/or damage. File a claim by calling the toll-free number, 1-800-440-0858 (TTY device 1-800-572-3053), or by submitting a form online:

If you file a claim via the toll free number, 1-800-440-0858 (TTY device 1-800-572-3053)

  • You will be given a claim number by the call center. It is important that you keep your claim number. You will need this information.
  • After you have your claim number, a claim adjuster will contact you, or you can visit a claim center.
  • If you visit the claim center, you will need to have documentation to support your claim and a photo ID.
  • If you talk with a claim adjuster on the phone, documentation can be sent by mail, email, or fax.
  • See below for what type of documentation is needed for each type of claim.

If you file a claim online at

  • You will be called and provided a claim number, usually the same day.
  • After you have your claim number, a claim adjuster will contact you, or you can visit a claim center.
  • If you visit the center, you will need a photo ID and documentation to support your claim.
  • If you talk with a claim adjuster on the phone, documentation can be sent by mail, email, or fax.
  • See below for what is needed for each type of claim.

Visit a Claims Office

You may visit one of the 25 BP Claims Offices; however, we recommend that you first obtain a claim number by calling the toll free number 1-800-440-0858 (TTY device 1-800-572-3053). This will help avoid delays.

Claims by mail

You may submit a claim via mail by sending it to: ESIS, One Beaver Valley Road, Wilmington, DE 19803

Other information

You should only file one claim. You can report different types of damages on the same form with the same claim number. Exceptions include if you are reporting property damage for more than one real estate property. If this is the case, file a separate form for each address. Claim adjusters can answer any questions or deal with exceptions.

Claims that are of large monetary value or are based on complex economic predictions of loss should be sent to ESIS, One Beaver Valley Road, Wilmington, DE 19803. These claims will be handled by specialized adjusters with the assistance of accountants and lawyers.

Government entities

States, parishes, counties and local government and other political subdivisions that have incurred expenses responding to the Deepwater Horizon Incident and oil spill will have a separate dedicated process. Government entities can send their claims to ESIS Government Entity Claims, One Beaver Valley Road, Wilmington, DE 19803. The fax number is (302) 476-6272. Local government entities may submit claims by phone by calling (302) 476-7732. All government claims will be handled by a specialized team and will be given high priority.

BP has made advanced funds available to the states of Louisiana, Mississippi, Alabama and Florida, as well as several local parishes in Louisiana. Local Government Entities are not required to submit claims to the states and parishes who received advanced funds prior to submitting claims to BP.

Supporting documentation

You will need to provide photo ID and documentation supporting your loss. Below is information about what is needed to support various claims.

Loss of income or net profit claim documentation can include:

  • Tax records
  • Trip tickets
  • Wage loss statements
  • Deposit slips
  • Boat registrations
  • Copies of your current fishing license

Deckhands and others that work on a cash-only basis can also submit claims. They will need to provide photo ID and a copy of a pay stub or another document showing how much money they earn. They will also need to provide a phone number for their captain or manager to confirm employment.

Commercial economic loss claims may require additional business specific records.

Property damage claims can require photographs and replacement or cleaning receipts.

Larger property damage claims may require on-site inspection by a claim adjuster.

Loss of rental claims can include prior occupancy rates, cancellations, tax records, and bookkeeping records.

Bodily injury claims are not payable under the Oil Pollution Act of 1990; however, BP will evaluate each bodily injury claim submitted on a case-by-case basis. You will need to provide medical records, medical bills, or pharmacy records to support the claim.

Loss of income or net profit

Loss of income or net profit payments are made in advance because individuals and businesses need to pay their bills. Advance interim payments are made to claimants who are not receiving their ordinary income or profit while the cleanup is underway.

The process works as follows:

  • Once your supporting documentation is received, your claim will be evaluated, and you will be notified if an advance payment will be provided for your claim.
  • The advance payment will be up to the equivalent of one month lost income, based on documentation you provide. The advance is not based on actual income, and you may receive supplemental payments if documented losses are larger than the amount of the interim advance payment.

Second payments

If you were given an interim advance payment for loss of income or net profits before June 1, you are eligible for a second payment. The second interim advance payment will be for the same amount as the first payment you received. No check will be reduced.

Individuals and businesses will receive their second payment about 30 days after their initial advance payment was received. For example, if you received a payment on May 15, you will receive a second interim advance payment about June 15. Checks will be mailed to you along with a letter that is printed in four languages – English, Spanish, Vietnamese, and Khmer.

If you are receiving your first interim advance payment in June, the claims center will communicate with you about any further possible payments.

BP will continue to evaluate whether additional payments are appropriate because claimants remain out of work due to the spill.

Supplemental payment

If you have losses that are larger than the amount of any interim advance payment, you must work with a claim adjuster to discuss those losses. Those who have provided documentation that demonstrates the losses actually incurred are larger than the total amount of interim advance payments received will receive a supplemental payment for the difference. This payment will be provided by a claim adjuster after talking with the individual or business owner.

Help after you file a claim

You may call 1-800-573-8249 to check on the status of a claim if you have a claim number and have not heard from a claim adjuster. You should be prepared to provide your name, address and claim number so that the claim can be more easily located.

Legal representation

An attorney is not necessary to submit a claim to BP. Some claimants may want to seek the advice or assistance of an attorney. BP pledges to treat claimants represented by attorneys the same as claimants proceeding without the assistance of an attorney.

You and your attorney may prefer that you deal with BP or its adjusters directly. In that event, your attorney must consent in writing. To assist you, we have provided the attached authorization in the link below, which will allow us to communicate with you directly with respect to your claim(s).

Your attorney must send a letter of representation or the ‘Attorney representation form’ to ESIS, Inc.

Fax: 302-476-6272
Mail: ESIS, Inc.
1 Beaver Valley Road
1 West
Wilmington, DE 19803

If you are an attorney, filing on behalf of claimant(s), please fax a letter of representation to ESIS, Inc. at 302-476-6272

Translators available

Some of the Claims Offices are staffed with translators including the following:

For Vietnamese:

  • Bayou LaBatre, AL
  • Bay St. Louis, MS; Biloxi, MS
  • New Orleans , LA
  • Boothville-Venice, LA
  • Gretna/Belle Chase, LA

For Spanish:

  • Bayou LaBatre, AL
  • Bay St, Louis, MS
  • Orange Brach, AL
  • Mobile, AL

For Khmer

  • Bay St. Louis, MS

BP Community Offices also have translators. Additional translators will be provided as needed at Claims Offices.

Materials are available in:


A fraud reporting hotline has been established at: 1-877-359-6281. All potential claims of fraud, waste, or abuse will be investigated by a dedicated Special Investigation Unit, and where appropriate, submitted to authorities.

Anyone submitting false claims may be subject to civil and criminal prosecution under Federal law.

Our commitment to resolving pending claims

BP is committed to working with individuals to ensure that ALL legitimate claims are paid. We have asked the companies processing claims to assist individuals and businesses that may be experiencing difficulty identifying or locating necessary information.

BP deeply regrets that you have been impacted and inconvenienced.”

From the Social Security Administration…

§429.106 What happens if my claim is denied?

(a) If your claim is denied, the SSA Claims Officer will send you, your agent, or your legal representative a written notice by certified or registered mail. The notice will include an explanation of why your claim was denied and will advise you of your right to file suit in an appropriate U.S. District Court not later than 6 months after the date of the mailing of the notice if you disagree with the determination.

(b) Before filing suit and before expiration of the 6-month period after the date of the mailing of the denial notice, you, your duly authorized agent, or your legal representative may file a written request with SSA for reconsideration by certified or registered mail. If you file a timely request for reconsideration, SSA has 6 months from the date you file your request in which to finally dispose of your claim. Your right to file suit will not begin until 6 months after you file your request for reconsideration. Final SSA action on your request for reconsideration will occur in accordance with the provisions of paragraph (a) of this section.

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Sample Letter to Send for an Assignment of Benefits Denial

Assignment of Benefits Denial Sample Letter

Provider Appeals Department
City, State, ZIP Code

Re: Assignment of Benefits Denial

Health Plan ID Number: Group Number:
Insured/Plan Member: Patient Name:
Claim Number: Claim Date:

Dear Sir/Madam:

[Insert org name here] is deeply concerned about your apparent policy of ignoring a patient’s request to assign benefits for services to treating non-participating emergency physicians. We believe that this policy serves to undermine the unique relationship that exists between patients and emergency medicine providers, places a superfluous burden on the patient, and has the potential to fuel access to unnecessary services.

In fact, several states have enacted legislation mandating that insurers honor a patient’s assignment of benefits to non-participating providers of emergency care. Legislators and regulators are increasingly recognizing that a process whereby patients directly receive payments for performed emergency services, coupled with the fact that medical care providers cannot refuse to see anyone who comes to a hospital emergency department, might establish some pernicious incentives. When payment for services goes to the patient, the responsibility for its retrieval falls to the emergency medicine provider. We have observed that on occasion, some beneficiaries will retain this payment and, sometimes inadvertently or sometimes intentionally, not make their own payment for the services received. It is not difficult to see how such a system might provide an incentive to over utilize emergency medicine services in anticipation of inappropriately obtaining insurance payments.

As you are most likely aware, federal EMTALA law mandates that emergency department patients receive a medical evaluation, and any required stabilization and treatment. This stringently limits providers from restricting access to emergency medicine services, even were they so inclined to do so.

We ask you to reconsider your apparent policy with regard to this claim. And, we look forward to working with you to develop procedures so that in the future you can comply with patient requests to assign benefits to treating providers. Please let us know your respective decisions.
[Physician Name]

Copy: State Department of Insurance

Denied Claim


Good and hardworking people buy insurance for a simple reason – to protect themselves against loss. In today’s world, however, powerful insurance companies fail to investigate claims made by people who buy insurance. Worse, insurers delay investigation or deny claims to make money.


Helping people battle insurance companies is our life’s work. If you or someone you care about is being mistreated by an insurance company, hopefully we can help. By law, insurance companies have to treat you fairly. Here is some helpful information. We’ve obtained real results for real people. February 2009: If you have a question about your Insurance Disability Policy, click here.

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Family Stuck As Daughter’s Insurance Claims Denied

Feb 19, 2010 9:56 pm US/Central

Jane Slater
FORT WORTH (CBS 11 / TXA 21) ―

New parents Marshall and Mareya Proux said they are at wit’s end.

Their daughter 15-month-old Sophia Proux has cerebral palsy and suffers from a list of neurological complications.

“She can’t hold up her own head, she can’t roll over or sit-up. She can’t swallow liquids,” said Marshall Proux. “Several months ago she was supposed to be on solid foods but she can’t even chew.”

Their physician, neurologists and even The Journal of the American Medical Association say Sophia’s quality of life would be improved with a combination of speech, occupational and physical therapy.  But their insurance provider, United Healthcare, has twice denied their claim.

“We feel helpless there is nothing we can do,” said Marshall Proux.

Mareya Proux said the therapy, out of pocket, costs $3000 a month. She said would also get a job but finding her help for daughter and Sophia’s twin brother was costly and the children needed her at home.

Marshall Proux said they tried applying for help from the government but Medicaid and Social Security both denied their claim because he made to much money.

“I have to quit my job and go on welfare for help,” said Marshall Proux.

Proux said they hoped CBS 11 could help them avoid those options.

CBS 11 contacted United Healthcare and while the spokesperson was sympathetic she said the case required research and could not say why the claim was denied because it was “experimental”. The spokesperson promised they would personally contact the Proux’s and see if they could help them.

In full disclosure, United Healthcare is also the insurance provider for CBS 11’s parent company, CBS Corporation.

The Proux’s said they need help and this experience has taught them humility which means they will take help from whoever will help them.