Explanation of Benefits

Transcript: Hi. I’m Indiana personal injury attorney David Holub, and few things are more aggravating than getting a cryptic letter from an insurance company showing something was paid, but denying something else, but not providing you any clue as to why a certain amount was paid and why other amounts were denied.

This is particularly aggravating in health insurance. It’s called “explanation of benefits,” and insurance companies have an obligation to clearly and accurately explain why they’re paying benefits, why they’re denying other benefits, and to let you know quickly and promptly what they are doing to handle your claim.

All too frequently, we get letters from insurance companies with meaningless code numbers that say “this treatment is not covered,” “this procedure is not covered,” “we paid X dollars, you owe Y dollars.” Nothing is clear on these kinds of letters, and these kind of letters that do not give a clear explanation of benefits can constitute bad faith. In Indiana, claims benefits to insureds or their beneficiaries must be accompanied with a clear explanation setting forth the coverage under which payments are being made and sometimes the use of short billing codes or payment codes are okay, but they have to have somewhere in the letter, even perhaps on the backside, the explanation of what the codes actually mean so that you can determine for yourself whether you have been properly treated under the insurance policy.

In other words, you’re entitled to an explanation of benefits that is clear and understandable. If you think your insurance company has not been acting in good faith, call one of our attorneys today.