Small Claims Court for Health Insurance Reimbursement (in California)
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These are easy to read and understand and are beautifully presented.
Your ultimate tool is Small Claims Court - this is a system where you
can easily represent yourself and present your "case" to a judge:
You had an obvious medical need for appropriate care for a normal, healthy
pregnancy.
You pre-arranged coverage for a homebirth.
Your treatment was less expensive than the standard treatment, i.e. hospital
birth.
The insurance company refuses to honor their pre-arrangement to cover expenses
for your homebirth.
First of all, the legal cost to the insurance company in representing themselves
in Small Claims Court is large. The Public Relations cost is atronomical.
It just doesn't look good for them to be denying coverage for a less expensive
plan of treatment for homebirth, especially when they agreed to cover it
in pre-arrangement. Can you imagine a "60 minutes" piece about this.
Or maybe Anderson Cooper could champion the downtrodeen mothers who just
want to give birth without exposing their babies to drugs, and who just
want to have their babies near them so they can breastfeed, and who just
want to protect their babies from hospital germs, and . . .
You get the picture.
Small Claims Court is your trump card. Don't be afraid to use
it. It's actually quite easy.
If you didn't get pre-approval for your homebirth healthcare, you may
still be able to pressure your health insurance company to reimburse your
homebirth expenses through arbitration or by filing a claim in small claims
court.
Often, the consumer/member/subscriber can't file a claim in small claims
court because their health insurance policy (which is a contract), requires
arbitration instead.
For homebirth midwives, who are usually not able to become in-network
providers, their only legal recourse for repeated denial of claims is through
Small Claims Court. In California in 2006, the limit has been raised
to $7500, which makes it quite worthwhile to file a claim!
Steps to successful recovery of your fees through Small Claims Court
in California:
File claims that are sensible, accurate and use correct coding.
Respond to initial denials with appeals letters that describe how homebirth
care is different from hospital-based care, i.e. how the homebirth midwife
provides services normally fragmented among obstetricians, neontal teams,
pediatricians, and nursing staff, and the large collection of expensive
and specialized equipment that midwives bring to births.
Respond to second denials with the same appeal letter with a specific notice
that if the second appeal is denied, you will file a claim in Small Claims
Court.
If they deny your second appeal, gird your loins, take a deep breath and
remember that you're doing this so you make enough money to run a business,
maintain a professional midwifery practice, support midwifery organizations,
support yourself, make sure you have access to decent healthcare for yourself,
and maybe even put aside a little money for retirement!
