Steps to Negotiate the Insurance Maze


Obtain a copy of the full (not abbreviated or summarized) EXPLANATION OF INSURANCE BENEFITS. Read your policy carefully and thoroughly, including fine print, definitions, exclusions, etc., to learn the extent of covered services.


Find out if you have been assigned a CASE MANAGER and contact that individual; if not, request that you be assigned to a case manager or benefits advisor. To be your loved one’s best advocate, you should educate the case manager about his/her brain injury and particular needs to preserve the integrity of their body and health.


Determine the REHABILITATION BENEFITS. Inquire about the number of allowed days of coverage for inpatient acute and sub-acute rehabilitation, outpatient and home health rehabilitation; ask whether there is an annual maximum number of days and a lifetime maximum number of days.


Inquire about rehabilitation in a BRAIN INJURY-ACCREDITED REHABILITATION FACILITY, including both in-state and out-of-state facilities.


Contact your insurance representative for ISSUES AND/OR CONCERNS that relate to your health insurance and whenever you have been denied a service that you believe to be covered.


Remember to always document/record ALL CONVERSATIONS with your insurance company: Include the date of the call, the reason for the call, the person with whom you spoke and the outcome of the call.


Educate your INSURANCE REPRESENTATIVE to be an advocate for your loved one’s health care needs. Teach this person the risk factors for the secondary complications of brain injury, necessary measures to preserve the health and integrity of your body and importance of immediate access to insurance and health care professionals.


If your injury occurred while on the job and you have qualified for WORKERS’ COMPENSATION, talk to your Workers Compensation case manager about what options for care are available to you following your trauma care treatment.

Adapted from What You Should Know About Health Insurance: Guidelines for Persons with Spinal Cord Injury (National Spinal Cord Injury Association)