The administrative idea of exhaustion of remedies is daunting for those who are well, let alone those who are sick, but follow the steps. Your insurance plan will out line its appeal process. Read through and get those steps in order: Start with a claim form, have the insurance company statement explaining the processing of your claim form, prepare a form letter for yourself to use in the case of the need for appeal, you can use it for all appeals (include your policy number, blanks for date of service, blanks for claim number, blanks for date claim submitted, blanks for what has happened since you filed the claim eg claim submitted, claim denied, appeal filed, appeal denied).
Exhaustion is a descriptive word used for this process.
Now after the appeal is denied, where do you go? Many employer plans provide for an employer review of your complaint only after you have EXHAUSTED insurance company avenues. Okay, send them a copy of your file. After they go along with the insurer (usual), you can now go outside to your state insurance department.
For health insurance, ERISA is a killer in obtaining relief from insurance company practices. Basically, it is a federal law that is tilted in favor of any entity that helps pay for your insurance. So, Medicaid and Medicare, employer funded plans, you might be up a creek. You can still file claims but you have a real burden in bringing this kind of a claim.
Task a day insurance: When all the free market economy nuts (nuts because they incorporate the fraud, price fixing and loophole using behavior of theirs as some noble free market economy virtue) get what they want, start examining new opportunities. Once we've all been empowered to go out and hunt down our own insurance policy, and pay exorbitant prices for it, think of the upside: These new plans will be ERISA exempt. If nobody but you is paying for your health insurance you can sue, sue and sue again for every hideous thing an insurance company does. And we should.
