Having a health insurance policy is not a guarantee that all medical expenses will be covered. Most people expect everything to be covered after they pay the deductible, but many medical procedures are not covered by insurance.
Some claims are denied for specific reasons. The best way to get a claim covered that was denied is to write a clear and thorough health insurance grievance letter.
The success rate of appealing health insurance claims is 40 to 50 percent. This means it’s worth the effort.
Customer Service Department
It is recommended that the policy holder call their insurance company’s customer service department first to ask exactly why the claim was denied.
This may be enough to settle the issue. If not, the next step is to write a letter. It must adhere to the insurance company’s rules that are stated in the insurance policy.
Many people feel angry at the insurance company or the claims adjuster when a claim is denied. However, this letter is not the place to express anger, show irritation or be rude.
The tone should remain professional and use compromising words like reconsider rather than making demands.
Examine Insurance Policy
The customer should also look for any language in the policy that will help back their appeal. If there is any statement concerning making appeals, it should be included in the letter.
Enclose Medical Documents
The customer should enclose any documents that support their request such as medical records, radiology reports, a letter from their doctor and any notes the doctor made.
The following information should be given in the letter:
• The policy holder’s name, policy number, claim number and any other identification number connected with the insurance policy
• The reason the claim was denied in the exact language used in the denial
• A brief history of the illness and what treatments were ordered by the doctor
• The reason the denial was wrong, and supporting documents enclosed including a letter from the doctor who gave the diagnosis
• All pertinent dates, including the date of the accident or diagnoses of the illness, date of the insurance claim and the date of the denial
The letter should also state exactly what the policy holder wants done. It tell why the medical procedure is necessary and should be paid for by the insurance company.
Here is a sample health insurance grievance letter. It should clearly state the customer’s name, address and policy and claim number and be written in formal business style. The letter should be sent by certified mail, so the sender has proof of the time and date that the letter was received.
This may be necessary to produce if there is any question about the time limit. Any documents sent should be copies and not original documents.
All communication pertaining to the claim dispute should be kept by the customer. This includes the names of insurance company representatives, claims manager or supervisor.
Sample Health Insurance Grievance Letter
Name of Policy Holder
Address of Policy Holder
City, State, Zip Code
Director of Claims
Name of Insurance Company
Address of Insurance Company
City, State, Zip Code
RE: Policy Number NUMBER appeal for claim denied. Claim number NUMBER
Dear Name of Claims Director,
You denied payment for a procedure that was prescribed by my doctor NAME OF DOCTOR for me after an automobile accident on DATE. The denial stated that the procedure was not medically necessary.
The denial of this claim was not justified and I am appealing it. The explanation you gave for denying the claim was not adequate, since it didn’t include any report of a medical review of my situation, nor did it include the names and credentials of the insurance representative who did review my claim.
I would like copies of any medical opinion that caused the denial of my claim, so I can have the proper medical experts respond with the applicability of this treatment for my condition. Without the physiotherapy treatment, I will not have full use of my legs.
Please review my claim again. Enclosed is a new claim application with the information about the appropriate diagnosis and treatment. I have also enclosed a letter and notes from my physician.
I would like you to cover all the treatment I need to completely recover from the injuries I sustained in the accident.
If you need any further information, I can be reached at 555-123-4567 or at Name@email.com. I hope to get a favorable reply from you within 10 days.
Thank you for your attention to this matter.
Signature of Policy Holder
Name of Policy Holder Printed
List of Enclosures