What can I do if my health insurer denies my claim?

It’s not uncommon for a health insurance company to refuse to pay for medical treatment. If it happens to you, it doesn’t have to be the final word.

You can appeal to your insurer. If the answer's still no, you can appeal to an independent review organization. In addition to appealing a denial, you can also file a complaint with us.

If you want to file an appeal with your health plan, contact them and ask: “What do I need to do to file an appeal?” After that, you’ll need to collect materials that support your appeal, such as documentation from your medical provider and information about your medical condition.

After you send your appeal materials to the health plan, be persistent. Most people don’t win at the first level of appeal, but the odds of winning increase as you reach higher levels of appeals. The chance of winning is highest when your health plan appeal reaches the final level, called an Independent Review Organization.

Read more information and find letter templates and other pointers in the appeals section of our website. If you need help, file a complaint with us.

What happens if I lose my health insurance?

Health insurance is available only during a short window each year, called open enrollment. This year, open enrollment for individual and family health plans starts Nov. 1, 2019 for coverage to take effect in 2020.

However, certain events qualify you for a special enrollment, including losing your existing health coverage.

If you lose coverage that was provided by an employer, you are eligible to buy a COBRA plan, as well.

COBRA is a federal law that allows you and any of your immediate family members to stay on your employer’s health plan if you lose your job or your employer coverage.

COBRA can be expensive. People who choose COBRA coverage must pay the entire premium, including the portion previously paid by the employer, plus a 2 percent administrative fee.

Before you decide to go with COBRA, find out if you can buy a health plan through Washington Healthplanfinder and receive a subsidy to help pay your insurance premiums. If you don’t qualify for any subsidies, you can also purchase coverage directly from an insurance company, broker or agent.

Other events that qualify you for a special enrollment include:

• Having or adopting a baby.
• Moving to a new area that’s not covered in your existing plan.
• Getting married or divorced.
• A change in eligibility for your existing health plan. 
• Your health plan stops selling coverage in Washington state. 

Read more about special enrollment on our website. Questions? Contact our insurance experts or call 1-800-562-6900.

Consumer alert: What you should know about winter storm damage

A winter storm has hit Washington state hard, with record levels of snowfall in Western Washington and it may not be over yet. Forecasts call for continuing rain or rain/snow mix and possible freezing temperatures overnight in some areas.

A state trooper helps a motorist dig out
after sliding off the road on Highway 3 on Feb. 11.
Photo courtesy Washington State Patrol

Here are some tips about winter storm prevention and damage.

Auto damage

If you have comprehensive coverage, your policy should cover any damage caused by trees, ice or other weather-related mishaps. The amount of your deductible may sway your decision to file a claim, depending on how much damage there is.

A good way to avoid a weather-related collision to is leave yourself plenty of time to arrive at your destination and drive slowly. Get real-time tips from Washington State Patrol.

Also, it’s a good idea to park your vehicle in a protected area or away from trees that can damage it.

Boats and RVs

Be sure to check your boat and/or RV is you are storing one outside. Boats moored in marinas need to be checked, as the weight of ice and snow can sink a boat.

Snow/ice

The prolonged weight of ice and snow on buildings can lead to collapse or cause the roof to crack and let moisture in the home. Sometimes these cracks are not apparent, and may not be seen for a few weeks to a few months.

Another issue to be aware of is frozen gutters. If water collects in them and it freezes, it can cause damage to the house. Those claims can be contentious because sometimes the damage isn’t found until much later, so it’s hard to prove what actually caused the damage. To be on the safe side, clear debris from gutters so water doesn’t collect and freeze.

If it is not safe to remove snow or clean gutters, consider hiring a licensed and bonded contractor to do the work.

Snow melt

Some areas of the state are experiencing a rapid snow melt, which is good but may also cause problems for some people. Homeowner’s insurance doesn’t cover flood damage. You would need a flood insurance policy, which has a 30-day waiting period to kick in. So if you don’t have a flood policy and you experience flood damage, you won’t be covered.

Here are some tips for avoiding flooding on your property:

• Pile snow in a place that won’t cause water to flood any buildings as it melts. 
• Try to clear out accessible down spouts and storm drains to prevent backups and overflows. 
• If any of these activities are unsafe, you may want consider hiring a licensed and bonded contractor to do the work. 

Read more about winter weather and insurance considerations. Questions? Contact our insurance experts.

Kreidler helped consumers recover $15.9 million in 2018

Washington state Insurance Commissioner Mike Kreidler has a dedicated team of people who help Washington consumers with their insurance questions and  problems every business day of the year.

Here's how we helped more than 82,000 consumers in 2018:

• Received and processed 6,779 consumer complaints, resulting in the recovery of $15,916,013 for consumers related to insurance billings, refunds and various claim-handling issues
• Answered 73,983 calls to our consumer hotline regarding insurance issues, rights and responsibilities
• Answered 2,013 live chat insurance-related questions from consumers 
• Responded to 5,408 written consumer inquiries
• Mailed 1,725 insurance-related publications to consumers upon their request
• Made 1,105 in-person contacts with consumers at public outreach events
• Helped consumers resolve various policy issues, including claims, billing, and underwriting problems, and offered referral services to other state agencies and organizations, including the Washington Health Benefit Exchange

If you have an insurance question or complaint, contact us online or call us: 1-800-562-6900

Kreidler revokes Washougal agent’s license when she leaves her client uninsured

Washington state Insurance Commissioner Mike Kreidler revoked the license of Washougal insurance agent Jacqueline Cone last month when her client was left on the hook for $12,000 in damage after an auto collision.

Cone sold a Farmers Insurance auto insurance policy to a friend in 2017. The friend set up payments through her debit card, but told investigators that she switched to cash payments. In August 2017, Farmers canceled the policy because they never received the premium payments from the agent. In October 2017, the policyholder filed a claim with Farmers after a collision and was told that she was no longer insured. The company had mailed several cancellation notices but the policyholder said she moved and never received them.

The agent and the policyholder both told investigators that the cash payments had been made, but could not prove it. The agent told Farmers she accidentally applied the cash premium payments to the wrong person’s policy. Either way, the agent’s action violates state insurance laws. Farmers fired Cone in April 2018 and Kreidler’s regulatory investigation resulted in revocation of her license to sell insurance in Washington state.

Here are some tips for consumers:

• Pay your premiums in a way that leaves a record or paper trail. You want to be able to prove you paid your premiums. 
• Pay your premiums directly to your insurer – you can set up monthly, biannual or annual premium payments for just about every type of insurance out there. Set it up to come directly out of your bank account or billed automatically to your credit card. There is less chance of a mishap if you cut out the middleman – in this case, the agent. 
• Set up email notifications from your insurer. If there’s an app, make sure your phone is set to receive notifications via the app as well. You don’t want to miss notifications from your insurer that they haven’t received your premium payments. 
• It’s your responsibility to make sure your insurer gets your premium payments. 

Kreidler regulates the insurance industry in Washington state. Each month, he takes enforcement action  against insurance companies, agents, brokers and others in the industry and publishes a news release with those orders. You can sign up to receive email or text alerts with news from Kreidler.

Update: Flood insurance may be available during federal government shutdown

Update: We are seeing reports that NFIP will sell flood policies during the federal government shutdown, a reversal of its earlier announcement. While the FEMA website still says otherwise (see below), we've seen reports that NFIP is selling through its Write Your Own (WYO) partners, which are available from licensed agents and brokers.

Here's our original blog post:

During the federal government shutdown that started Dec. 21, the National Flood Insurance Program (NFIP) will not sell new flood insurance policies. According to the Federal Emergency Management Agency’s (FEMA) website:

“Policies that were in force before midnight on December 21, 2018 remain in force. The NFIP will process and pay claims under those policies as usual from the National Flood Insurance Fund and the National Flood Insurance Reserve Fund until depleting these funds, but will not have authority to borrow any additional funds from the U.S. Treasury. Existing flood insurance policies remain valid regardless of FEMA’s capacity to pay claims. FEMA and Congress have never failed to honor the NFIP’s contracts with policyholders.

The NFIP and its WYO partners (Write Your Own -- read more about what that means) may not issue new contracts for flood insurance during a lapse in authority unless Congress passes legislation reauthorizing the NFIP. During a lapse in authority, the NFIP will have limited ability to issue new policies, issue increased coverage on existing policies, or issue renewal policies.”

What does this mean for homeowners?
According to the Insurance Information Institute, Washington state had approximately 36,831 flood insurance policies through the NFIP as of 2017, the most recent data available.

Some mortgage lenders require homeowners to have flood insurance before they can close on the sale of a house. According to Reuters, it could affect up to 40,000 home sales each month.

While federal flood insurance policies are temporarily unavailable, there may be some flood policies available on the private flood insurance market. The best way to find out is to contact your insurance agent or company to ask if they can help you find private flood insurance.

Washington state Insurance Commissioner Mike Kreidler supports the development of a private flood insurance market, which would give homeowners and business owners more options and coverage choices for insuring their property. That could be one of the focus areas that would be included in a Washington state disaster resilience working group if Kreidler’s bill passes the state Legislature next year.

If you need help with an insurance problem or question, contact our consumer advocates.

Thinking about buying a condo? Here’s what you should know about insuring it

We talk to consumers a lot about homeowner and renter insurance, but condos are a type of housing that have unique insurance considerations.

The number of condos being built is on the rise in the Seattle area – more than 2,000 are slated to be built in Seattle and Bellevue through 2021. 

If the condo association owns the structure and common areas, it typically carries an insurance policy to cover damage to those areas and liability arising from those areas. The association policy may have a deductible that gets passed onto the unit owners, typically in the form of an assessment. It’s common that individual owners have little say with regard to how repairs are done, including the timeliness, quality and type – those decisions are typically made by the association.

Each unit owner should purchase their own policy that covers their contents and the space they own, sometimes defined in the policy as from “sheet rock in” or “paint in.” Unit owners can check with their agent or insurer to find out if there is coverage for the association’s deductible assessment under the unit policy.

The most common type of inquiry we receive from consumers involves claims where water damage to one condo unit affects another unit. Unless there is clear negligence on the part of the owner whose leak caused the damage, each individual condo unit policy pays for the damage to their own unit.

Questions? Contact your agent or insurance company. You can learn more about condo insurance. You can also contact consumer advocates online or by phone at 1-800-562-6900.

Avoid being the victim of package theft

December is the season for shopping for gifts, which means it’s also prime Grinch season for car break-ins and thefts.

Theft from a house

Packages left on porches by delivery services, and pre-wrapped presents under the tree, are vulnerable for theft, and proving the value and ownership might be a challenge. According to Property Casualty 360, 26 million Americans have had a holiday package stolen from a front porch or doorstep.

Talk to your agent about this type of theft and what you would need to prove you had your property stolen from your porch, driveway, mailbox, or house. Most insurers require a police report to accompany theft claims.

A couple of things to consider to try to avoid theft:

• Have your package delivered to a friend or family member who is home during the day. 
• Ask the vendor if they can deliver to a secure location. For example, Amazon can delivery packages to Amazon lockers. 
• Consider installing security cameras. They are widely available and have become more affordable as the technology improves. Some insurers offer a discount on homeowner policies if you have a security system – talk to your agent or broker about that. 

Car break-ins

If you find yourself the victim of a car break-in when you have a car full of gifts, your homeowner or renter insurance will cover the contents, but there could be dollar limits on certain types of property. Talk to your agent about any policy limits that may apply to certain types of personal property.

If you decide to file a claim – for instance, if your car was damaged during the theft -- make sure you have receipts for what was stolen and a copy of the police report, if you filed one. However, you should consider whether your claim amount is more or less than your deductible. If it’s less, not only will you pay more than the value of the goods, but you may not want to run the risk of your insurance rates going up as a result of the claim.

It’s best not to store packages or valuables in your car. If you need to, stash them away out of plain sight before you park. 

More info

• Read more about understanding your homeowner or renter insurance. 
• Read more about understanding your auto insurance. 
• Questions? Talk to one of our insurance experts.

Tips to avoid Medicare card scams

Medicare has been mailing new Medicare ID cards to Washington state beneficiaries since September and scammers are taking advantage of this opportunity to commit fraud.

The cards have a new look but, most importantly, they have unique numbers to replace the Social Security numbers previously used on the cards. Medicare created the new cards to reduce identity theft and fraud. 

Here’s what a scammers may say when calling Medicare beneficiaries (note: none of these is true!):

• Ask for your bank account information so you can pay for your new Medicare card. 
• Ask you to confirm or give your personal information to get your new card. 
• Ask for your old Medicare number (which was your Social Security number) to prevent your Medicare coverage from being interrupted. 

Facts about the new Medicare cards

• They are FREE! You do NOT pay for your new card and you don’t have to do anything to get it. Medicare will automatically mail your new card to you. You can sign up to get an email from Medicare to know when to expect your card in the mail. 
• You do NOT need to give any personal information to get your new card. The cards are mailed to the address you have on file with Social Security. You can update your address online, call 1-800-772-1213, or visit your local Social Security office. 
• Your Medicare coverage will NOT be interrupted or stopped because your new card’s being mailed to you. 
• In general, Medicare will never call you uninvited and ask for your personal information, or to get your new Medicare Number and card. 

What to do if you get a call

If you receive a call or email that seems suspicious, do not share any information. Hang up and call our Statewide Health Insurance Benefits Advisors (SHIBA) at 1-800-562-6900 to report the incident.

In addition to providing free, unbiased help with your Medicare options, SHIBA is Washington state’s Senior Medicare Patrol project. We help clients prevent, detect and report Medicare and Medicaid fraud and abuse.

Diabetes & health insurance: What you should know

November is Diabetes Awareness Month, and there are a lot of reasons to be aware of this disease. Worldwide, 425 million adults have diabetes – that’s one in 11 people. Another 212 million people remain undiagnosed – or 1 in 2 people.

Health insurance subject to the Affordable Care Act (ACA) and Medicare are required to pay for diabetes screenings and other preventive services in full, without cost-sharing. If you’ve already been diagnosed with diabetes, the ACA prevents insurance companies from denying you coverage based on having a pre-existing condition.

Washington state law goes further and requires health insurers to cover the following:

• Insulin 
• Syringes 
• Injection aids 
• Blood glucose monitors 
• Test strips for blood glucose monitors 
• Visual reading and urine test strips 
• Insulin pumps and accessories to the pumps 
• Insulin infusion devices 
• Prescriptive oral agents for controlling blood sugar levels 
• Foot care appliances for prevention of complications associated with diabetes 
• Glucagon emergency kits

Find more information about diabetes:

• American Diabetes Association
• Washington state Department of Health 
• Could you spot the warning signs of diabetes in your family? (quiz) 
• Beyond Type 1 

If you believe you’ve been denied coverage for a preventive diabetes screening, diabetes treatment, or diabetic supplies, you can talk to an insurance expert or file a complaint.

Quitting smoking can improve your health insurance premiums

Today is the Great American Smokeout and now is a great time to stop smoking and using nicotine products to avoid the nicotine surcharge for your 2019 health insurance.

Health insurers are allowed to charge smokers 50 percent higher premiums than nonsmokers. That’s because smokers' health care costs tend to be higher than those of nonsmokers.  

To help you kick the habit, the Affordable Care Act requires health plans to cover FDA-approved smoking cessation services such as counseling and medication as a preventive benefit, which means consumers have no out-of-pocket costs. 

• Medicare also covers smoking cessation services. 
• Small employers can avoid the tobacco surcharge by participating in a wellness program.
• Tobacco use is not disclosed on Medicaid plans and the rates are not affected.

Here are some tips from the Great American Smokeout for how to quit using tobacco products:

• Quitting smoking isn’t easy. Have a plan for how you will live a smoke-free life.
• You don’t have to stop smoking in one day. Start with day one.
• How to quit smoking or using tobacco. 

There are immediate and long-term benefits to quitting smoking, beyond paying less for health care (and saving money you’ve been spending on cigarettes or nicotine products). 

Nearly 38 million Americans still smoke cigarettes, and smoking remains the single largest preventable cause of death and illness in the world. Smoking causes more than 480,000 deaths every year, about 1 in 5 deaths. And more than 16 million Americans live with a smoking-related disease.