Claim Denials? Don't Panic! Unlock the Power of Insurance Departments

Claim Denials? Don't Panic! Unlock the Power of Insurance Departments

Like too many cancer patients, I’ve been denied health insurance coverage for necessary care. Navigating health care coverage is never a fun task, and cancer survivors – as well as our families – are doing that on top of dealing with a life-changing diagnosis, financial stress, and serious challenges to our physical and mental health. I will never forget the call from our oncologist, when he shared that my next generation sequencing results found RET. “We have great targeted therapy for RET,” he said. “I’m calling in your prescription right away.”

We were flooded with relief and hope! Two days later, while we were waiting on Blue Cross Blue Shield of North Carolina to approve Retevmo coverage, blood clots in my lungs sent me to the emergency room.

My blood oxygen had dropped from the mid-90s the previous week to the mid-80s. My doctor advised that I should start Retevmo – my first-line treatment – right away. We were grateful to have a sufficient amount of credit on my card to pay the $11,000 out-of-pocket cost for 15 days of Retevmo. Blue Cross approved Retevmo less than 48 hours later, after we paid for it out-of-pocket from my emergency room bed.

We spent the next year communicating back-and-forth with Blue Cross, primarily through their online portal, about reimbursement. It was not until we contacted the North Carolina Department of Insurance (DOI) that things started to move. I received a phone call from a DOI representative within a day of leaving my message with their insurance dispute department. She was compassionate, informed, and eager to help us recover the full among we paid out-of-pocket under those emergent circumstances.

I relayed the facts about my situation and history of delays from Blue Cross. She documented everything and then reached out to Blue Cross directly for a justification on their part for their delay. Within two weeks, we received a call from Blue Cross to say that they would be mailing us a check for the full reimbursement for our out-of-pocket Retevmo payment.

Every US state has a DOI. Among other matters, it is their responsibility to help you:
  • Understand your insurance policy
  • File a complaint or appeal with your insurance company
  • Identify enrollment opportunities for health insurance coverage
  • Provide counseling for Medicare-eligible individuals
Departments of insurance provide critical oversight of private insurance companies and can also help you navigate the Medicare system. I wish I had contacted the NC DOI sooner, but I am so grateful for their empathy, expertise, and support once I did.

If your insurer has denied a claim, or if you have questions of any kind about your health insurance policy, you can look up your state’s DOI here. These public agencies are here to support you.
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