How to Prepare a Health Insurance Appeal Letter

Health, in general, is always a taboo topic that most people either shy away from, or perhaps wish they never have to deal with. Even scheduling maintenance health checkups are met with trepidation.

Needless to say, when you or someone you care for truly needs medical attention, the anxiety meter can shoot through the roof. Not only are you dealing with the underlying ailment, but you also must worry about the expenses that come along with treatment and care. Although the Affordable Care Act made rejection of coverage for pre-existing conditions unlawful, carriers still hold quite a bit of power, and deny coverage in a host of different scenarios. A person’s anxiety regarding health, often centers around the question of if they are covered or not.

Fortunately, you’re not completely at the whim of health insurance providers. If you do find yourself in a situation whereby your health provider has formally denied coverage for you or someone you care for, note that you can actually appeal their decision. Nationally, health insurance claim applications are denied approximately 19% of the time. That said, if an appeal is filed, those same denials of coverage are reversed circa 40% of the time. The overwhelming takeaway is that you should never lose hope if you receive a denial letter. Instead, you should redirect your focus to getting organized, and putting together a thorough health insurance appeal letter.

We certainly hope you never find yourself in a situation whereby you need to create an appeal letter. However, if you do, the example below provides a great basis to begin your process of showing your insurance carrier that they simply made a mistake, and that you or the person you care for should in fact be covered under the policy.

EXAMPLE HEALTH INSURANCE APPEAL LETTER

[Date]

[Insurance Contact Name]

[Insurance Company Name]

[Address]

[City, State ZIP]

Re: [Denial of Coverage]

[Patient’s Name]

[Type of Coverage]

[Group number/Policy number]

Dear [Insurance Contact Name],

I am writing on behalf of [Patient Name], to appeal [Insurance Company Name]’s decision to deny coverage for [Procedure or Treatment Name] to [Patient Name].

It is our understanding, that according to your letter dated [Insert Date] that [Health Plan Name] is denying coverage on the basis that “[Health Plan’s Language, Verbatim, and Attach Letter].”

[Patient Name] was diagnosed with [Ailment], [Date diagnosed.] [Patient Name] has since been receiving treatment from Dr. [Name] at [Hospital Name] diligently. Dr. [Name] is a specialist in [Name of Field] and believes [Procedure of Treatment Name] will aid [Patient Name] in his/her road to recovery. Dr. [Name] is willing to discuss the details with you personally, if you request. In addition, please find attached a letter from Dr. [Name] detailing the procedure, potential timeline and expected benefits. We have also attached [Patient Name]’s medical records, and research regarding the procedure, for you to review.

Given the research surrounding [Procedure or Treatment name], in addition to Dr. [Name] recommendation, [Patient Name] is requesting that you reconsider your initial denial for [Procedure or Treatment name.] Please do not hesitate to contact us should you require any additional information or have follow up questions.

We look forward to hearing from you.

Sincerely,

[Your Name]

[Phone Number]

[Address]

[City, State ZIP]

Remember to keep a copy of your health insurance appeal letter and paper trail of correspondence, which should include confirmation of sending the letter, and confirmation from the insurance carrier of receipt. In order to ensure the letter is delivered accordingly, send it certified mail and track it.

Best of luck with your appeal process, and note that even if your appeal is denied, find out why, and try again. What’s most important is that you don’t give up! If you need health insurance coverage anytime, please visit EINSURANCE.com to compare coverages from top insures for free.