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Consumer Reports Explains Insurance Concerns

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RALEIGH, N.C. — Five On Your Side receives a lot of complaints about insurance coverage. Many of the complaints involve issues where the insurance company says, "Sorry, that is not covered." A lot of consumers just accept it, but

Consumer Reports

says consumers need to fight back.

Whether it involved dental work, the birth of a baby or some sort of cancer treatment, many people have had problems getting medical care covered by insurance providers.

Susan's husband has Lou Gehrig's disease, a debilitating neurological disorder. His insurance company simply decided it would no longer pay for round-the-clock nursing care, but Susan fought back and with the help of an attorney, she got the coverage reinstated.

Consumer Reports

says too often people do not do that.

"I wish I had known I had more rights because the panic I was feeling was overwhelming," Susan said.

According to

Consumer Reports

, if you think you are right and something should be covered, then you should file a grievance. You should go to the HMO, go through all the steps the HMO requires and, if necessary, take it to the state.

Another option for consumers having a problem with an HMO or PPO is to seek free help online. A

Web site

co-sponsored by Consumers Union posts step-by-step advice on how to handle such problems.

Consumer Reports

says the Web site explains how to prepare an informal complaint or a formal grievance, goes through the grievance review process, arbitration, and even provides a checklist on how to appeal to a health plan.

Consumers in North Carolina will soon be able to get even more help resolving insurance disputes.

Within the next two to three weeks, North Carolina's Department of Insurance is starting an External Review Board, which will consist of a team of independent doctors who review disputes between patients and their health plans and then decide how to resolve them.

©2002 Consumers Union of U.S., Inc. All rights reserved.