Having healthcare insurance in place does not guarantee that every medical expense will be covered. Unfortunately, a lot of people find it surprising that even after paying their deductible, they are still left with some bills to pay because the insurance company has denied their claim. It is believed that 70% of claims that are denied were done in error, however, which is why it is so important that you look into this properly. If you are denied a claim, you need to appeal that decision. In fact, between 40% and 50% of all appeals are successful, so it is certainly worth trying it.
Before Writing a Medical Insurance Appeal Letter
The first thing you need to do is telephone the customer service department to find out why your claim was denied. It is possible that there is a simple error that can be resolved there and then. If not, then you do need to write an appeal letter, which has to follow the guidelines as stated in the policy. It is likely that you feel very angry and want to lash out at the claims adjuster. However, you should avoid that. Instead, try to maintain a professional and polite tone. Do not tell your insurance company to revise the decision, in other words. Instead, ask them if they could reconsider it.
Make sure that you truly understand your policy as well. There may be a time limit associated to when you can appeal a decision, so make sure to comply with that. Furthermore, you should find language in the policy that is on your side. Hence, make sure to highlight the elements of the policy that discuss appeals.
Content of the Appeal Letter
Make sure that your letter contains documented evidence supporting everything you say. For instance, you can include doctor’s notes and letters, radiology reports, medical records, and so on. Your letter should also include:
- Your name, policy number, identification details, and claim number
- The reason given for denying your claim, using their language
- A history of the medical condition and the treatments that were received
- Why you believe the denial was wrong, adding supporting information such as a doctor’s letter to confirm diagnosis
- All relevant dates, such as the date of the diagnosis, the date of treatment, and the date of the denial
Your letter should also explain what you would like the next steps to be. For instance, you may feel that the insurance company should compensate the bill in full. Do make sure that such is not done in a demanding tone, however.
Remember that you are writing a formal letter and it should be treated as such. It should not contain any grammar or spelling errors, and it has to be properly addressed. Ask someone to proofread it for you if possible. Also, keep photocopies of everything that you have sent, and send your letter via recorded mail. This gives you a paper trail to demonstrate that you have been proactive in resolving the situation. If you do not hear back from them after a week, make sure that you follow up.
Medical Insurance Appeal Letter Example
{Name}
{Address}
{Phone #}
{Date}
Dear {representative}:
I was shocked and dismayed to receive notice on {date} that {insurance company} denied payment for {procedure}. I’ve received a bill from {physician/medical center} for {amount}. I cannot pay this.
Before consenting to {procedure}, I contacted your company to ensure that the doctor and facility were in-network. In an abundance of caution, I also obtained the “code” for the procedure. Nevertheless, the denial letter states that {procedure} was not covered due to {reason}.
This is egregious and unacceptable. I did my due diligence and now the entire financial wellbeing of my family, not to mention future heath care for {condition}, is in jeopardy.
Please take all necessary steps to rectify this error. It is causing my family great stress at a time that we should be focused on recovery.
Sincerely,
{Sender Name}