Legal Issues: Health Insurance

Health insurance has become more complicated in recent years as managed care companies have grown to dominate the industry. In some cases medical decisions are made as much - or more - on the cost of treatment as they are on a doctor's medical opinion. To obtain appropriate medical care, persons with chronic fatigue syndrome (CFS) must often become their own advocates in the health care system.

Get the contract
The first step in advocating for your health benefits is to get a copy of your insurance contract and read the provisions of the policy or plan. The member benefits book provided by the insurance company when you sign up probably does not contain a thorough description of the rights and limits of the policy. You may have important rights the member book doesn't tell you - for example some policies will reimburse a portion of the cost of out-of-network specialist care if there is not a qualified CFS doctor in your area.

Find someone to help you
Comprehending all the technical terminology in insurance contracts is difficult for healthy people, and for people experiencing cognitive problems due to CFS it can be especially complex. A trusted family member or friend may be able to help you muddle through insurance documents and medical records to ensure that your rights and responsibilities are maintained. Someone who has experience reading legal documents would be most helpful.

Understand your records
Medical information can be as difficult to understand as legal jargon. Obtain copies of your medical records - you may have to pay photocopying fees to the doctors' offices, but it's important that you know what may be in your records that could influence an insurance company's or health care provider's decisions. If your symptoms are making it difficult for you to understand the information in your files, consider appointing a trusted family member or friend to help you coordinate your medical care. The release form below can be used to allow an advisor access to your medical and insurance records.

Appeal denials
If the insurance company denies payment for a treatment or procedure that your doctor says is medically necessary, submit a written appeal. The appeal procedure should be outlined in your contract. It can be helpful to quote the insurance contract's own wording to support your right to coverage for denied care. If you feel like you need additional help, consider hiring an attorney with experience in handling health insurance problems.

Sample Medical Records Release Form

You can use the following text to give a trusted advisor access to your medical records. This form does NOT allow medical decisions to be made on your behalf.

To Whom It May Concern:

____________________ (name of patient) hereby authorizes the release of all of medical and insurance records to _________________ (name of advocate). The name of the insurance company is __________________, the insurance policy number is ____________________ and the patient's Social Security number is ___________________.

A photocopy or facsimile of this Authorization shall be as effective as the original.

Date ________________

___________________ (patient's signature) (name of patient)