Anyone who's ever done business with a health insurance company, whether an HMO, PPO, traditional fee-for-service, or even Medicare or Medicaid, knows it can be a difficult and maddening process. HMOs, government programs and other carriers exist to make money. Most companies make it a policy of writing as few checks as possible and denying as many claims as they can. "Companies are willing to pay $40,000-60,000 a year to employees whose sole job is denying benefits," says Bob Ludlow, who practices law in California and Hawaii and has lived with quadriplegia for nearly 48 years.

"If you die, your heirs have no problem obtaining the full benefits of your life insurance coverage. If you get hurt, you have to fight for the benefits outlined in your health care policy, and often get less than half of the maximum," adds Joseph Romano, a Pennsylvania lawyer who represents injured and catastrophically ill individuals.

These two attorneys suggest some tactics when dealing with tightfisted companies.

Show Me the Policy
When all else fails, read the policy. "Insurance companies often misstate the law, as well as what they cover," Ludlow says. Both he and Romano stress the importance of obtaining a complete copy of the policy, which is much more explicit than handbooks given to employees. Beware of copies of sections of the policy that companies send to back up their denials--you need the entire policy. You must know the limits of your policy so that you can choose just what benefits you want. "You want to avoid shooting your entire durable medical equipment allowance on one piece of sexy equipment," Ludlow warns.

Often just getting the policy constitutes a major challenge. The place to start is reading everything in the handbook, then calling the toll-free number to request a complete copy, which is what the companies use when reviewing claims. If you have difficulty obtaining one, get your employer's human resources or benefits office to call the carrier. Call the hospital billing department, your doctor or your vendor, all of whom can be enlisted as allies. Should these steps fail to produce the policy, contact your local state representative, U.S. congressman or senator. Complain to your state insurance commission. If all else fails, hire an attorney and threaten a bad faith claim. These same tactics hold true for Medicare and Medicaid: If you have difficulty obtaining the fine print, get government officials involved. Use the same measures to obtain treatment and practice guidelines, which are often as important as the policy itself, but not always included.

Keep a binder of all your medical records. Complete and accurate records are critical to documenting your condition or progressive deterioration due to aging. They make it easier for medical professionals to advocate for you. Records should include all original x-rays, MRIs, muscle/sensory testing and other pertinent information, including recommendations and purchase records.

"When dealing with insurance companies, nothing exists except what medical professionals write down," Ludlow says. You're entitled to medical records upon request. If you're asked to pay for them, save some bucks by seeking out a doctor-even your childhood physician-to request them for you.

It's good to know helpful people. Begin with friendly docs, as they can make life easier. A physician's request for medical records often elicits a speedy, no-cost response. A physician who's a friend is usually much more willing to advocate for you and more amenable to listen to your needs. You need a professional who's willing to spend time with you and write a letter in medical language stating your requests. Credentialed signatures count. Nurture the relationship by doing as much footwork and research as possible; if you already have a summary of your medical history, docs will love you for it.

A friendly doc is a wasted resource if you don't know what you want or need. "You have to fully explain to medical professionals the extent of your injury so they can make a thorough argument for what your necessities are," Ludlow says. Often this means knowing more about your body than your doctor. To develop a thorough understanding of your condition and needs, request pertinent articles from a medical librarian, or use MEDLINE, part of the U.S. National Library of Medicine Web site.

Use local providers so you have someone to deal with potential equipment problems. Friendly vendors and suppliers who are flexible and willing to advocate for you can be helpful in several ways: by helping you avoid unnecessary purchases; by letting you demo equipment before ordering it; by ordering a needed piece of noncovered equipment (such as a suspension chair) and writing it up as a comparably priced piece of covered equipment (such as a more conventional chair).

Bargain and Barter
Explore extracontractual agreements or conversions that go outside the normal policy coverage. Conversion means swapping one type of covered benefit for different benefits which may not be covered. For instance, by explaining the high cost of skin surgery--easily $75,000-$100,000 a pop--you can make a case for paying for a visiting nurse to do weekly, noncovered skin checks. In order for conversion agreements to work, you've got to argue the downside of not swapping coverage and the upside of preventative maintenance. Both Ludlow and Romano have had considerable success with this.

"I once had a handcycle covered as a prophylactic device to prevent weight gain," says Ludlow, "by pointing out the amount of PT/OT needed by sedentary wheelchair users who are very prone to excessive weight gain."

Making these arguments requires forethought, research and documentation. Have all the facts and statistics in order. Have medical professionals ready to argue the merits and cost-effectiveness of conversion with logical and dollars-and-cents arguments. Making these agreements work requires dealing with someone who has some authority and power to overturn denials, which usually means at least a case manager or supervisor.

Playing on Their Field
Newspapers, television news and political campaigns are loaded with stories of absurd claim denials and individuals struggling to maintain quality of life, or even life itself, because of the common practice of claim denials. Just as companies know that less than 20 percent of people with catastrophic injuries file appeals, you need to know that more than 75 percent of those who appeal with an advocate--normally an attorney--are successful without a lawsuit. Administrative law judge appeals for Medicare and Medicaid are equally successful.

Keep accurate records of all communications, including dates. Always get the name of the representative you're dealing with, and always insist on getting denial rulings in writing; once you have the reason for denial, ask your doctor for a letter of medical necessity. Increase your chances for success by requesting an outline of the appeals process so you can know what to expect. Appeals are like mini-trials. Romano suggests knowing the following:

• The length of the hearing.
• The specific reason for the denial. Beware of phrases like "not medically necessary," "experimental" and "custodial," which are conclusions, not reasons.
• The number of company representatives involved in the hearing.
• Do all the reviewers have the original denial or your appeal? Send sufficient copies to the appeal board along with instructions to distribute copies to each reviewer.
• Your appellate rights if the appeal is denied.
• Whether benefits will be paid (if an inpatient) during the appeal. Benefits for existing services often continue during this process.

If you can't find someone to represent you, do it yourself. "There's no magic to legal arguments and legal know-how," Ludlow asserts. "People who are thorough and simple in their approach can win because they have a just cause. People who shoot straight in a simple, commonsense manner often prevail. Others lose out by waiting until their argument is perfect." If you should be denied, however, don't assume you can't get another doctor to support a case for your request.

Knowing the Rules
Anyone in the business of offering health care coverage has a good faith duty to abide by the policy, or provide good cause for denying or withholding benefits. Many companies will delay making payments for as long as possible. Most of us have been there, dealing with representatives who say the check's in the mail, they never received the claim, the claim is under review, or your request is disallowed by the policy. They delay, stonewall and sometimes even lie.

Joe Romano calls it bad faith, and offers this simple rule of thumb for refused requests: "If it [the denial, stalling or general runaround] doesn't make sense, it's probably bad faith."

"When things aren't paid for promptly, when denials are recurring for no apparent reason, if the problems appear to be part of the normal business practice for your company, find an attorney and pursue a bad faith claim," urges Ludlow.

What's a bad faith claim? Romano offers some examples:

• Failure to confirm existing health care coverage.
• Failure to provide the policy.
• Misrepresenting facts or coverage as stated in the policy.
• Failure to provide the full policy, treatment and practice guidelines and definitions.
• Failure to provide scientific evidence by a physician which supports treatment and practice guidelines.
• Delaying benefit payments by demanding multiple forms or documentation.
• Failure to inform the claimant or family of their appellate rights in a timely manner.

Understanding the rules of the policy and bad faith is important because many companies use fine print as an ally, expecting people to not question what they don't understand. You often need a lawyer familiar with insurance law to represent or at least advise you.

"I wish there were a course on assertiveness, because it empowers people to beat up on these insurance companies," says Ludlow. "People need to fight and use all the resources they have. They can have their employer write a letter on their behalf; they can complain to the state insurance commission; they can enlist the support of high profile figures like Ted Kennedy or Joe Biden."

Romano sees the bottom line as "getting everything in writing, along with specific reasons; aggressively pursuing denials for things you need; and filing a bad faith law suit, if necessary. This is where people need to be squeaky wheels, because it's their money."

Employee plans severely limit the bad faith claim option, Ludlow warns. "A 1987 court ruling--Pilot Life v. Dedeaux--limited bad faith claims to policies where the employer is a government agency, a religious group or a private plan. About 90 percent of policies are employer plans that have no right to bad faith claims," he says. "The plan administrator must be shown to have abused his discretion in the denial in order to even recover benefits offered by the plan."

"Much of this comes down to what I call a Vulcan mind shift," says Romano. "People should assume the attitude that they're entitled to care and equipment until the insuring agency proves that they're not."

This assumption is critical. Insurance companies, Medicare and Medicaid all have the burden of proving why they shouldn't pay your claim. Insurance companies often set up the rules, make them incredibly complicated, and then refuse to play by them. Your job is to is to be assertive, aggressive and relentless in pursuing what you need. They're always quick to remind you that a contract is a contract; it is, so hold them to it.

Joseph Romano has been profiled in The Wall Street Journal, and his book, Legal Rights of the Catastrophically Ill and Injured: A Family Guide, is free for the asking. Contact his offices at 800/331-4134, or e-mail him at info@josephromanolaw.com.

Bob Ludlow has lived with a C5-6 injury since 1952 and has practiced law since 1964. He is founder and president of Health Insurance Consumer Advocates, an organization dedicated to assisting people in the full recovery of medical expenses. He can be reached in Santa Cruz, Calif., at 831/475-5592, or e-mail rhludlow@aol.com.

Both Romano and Ludlow have been counsel or co-counsel in over 100 cases which resulted in million dollar rulings.