Law gives you new appeal to combat health-care denials

By Lorraine Simpkins
As a health-insurance consumer you have a new weapon to fight for health-care services you want, but your insurance company says you don't need.

A new state External Appeals Law takes effect July 1 which establishes an external review process for all health-care-services denied on the grounds that the service is not medically necessary.

It also establishes an external review process for patients with life-threatening or disabling conditions who want to participate in clinical trials, use off-label drugs or use experimental or investigational procedures or treatments when such services are denied on the basis that they are experimental or investigative.

To be eligible for an external appeal, you must first exhaust the insurance plan's internal-review process.
The law permits plans to charge you up to $50 for an external appeal, but they must give the money back to you if you win the appeal.

Randomly assigned agents certified by the state will do the external reviews. These agents are required to make a determination on an appeal within 30 days or three days for emergency cases.

Your health plan will send you more information on the new appeals process. You can find a summary of the law through the NYS Insurance Department web site at hyperlink http://www.ins.state.ny.us clicking on Health Related Insurance Laws.

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