The benefit of an insurance policy is the promise of financial protection in an emergency. Of course, having that protection denied in a moment of need is painful and disappointing. However, you don’t have to accept the denied promise, especially if you believe the benefit is genuinely deserved.
The Affordable Care Act (ACA) gives an insurance policyholder the right to appeal a denial of an insurance benefit claim to pay for a medical expense. A denied insurance claim can be overturned through this process, and the appropriate benefits awarded. Taking full advantage of this privilege under the act begins with creating an insurance appeal letter.
An insurance appeal letter is a written request issued from a policyholder to an insurance company asking for a reassessment of an earlier decision of the company to deny a benefit.
The appeal letter details the matter regarding which a benefit was denied and why the policyholder believes this should not have been so. In this way, the insurance company is made aware of the complaint by the policyholder. The company can then review the earlier decision, taking into account whatever argument the policyholder makes, and choose to either overturn the decision or reaffirm it.
Purpose of Insurance Appeal Letter
An insurance appeal letter aims to inform an insurance company of a complaint from a policyholder about a denied benefit. This letter is a means of tabling this complaint and presenting relevant information to convince the insurance company to reconsider. Insurance appeal letters are used following a notification from an insurance company that expresses an expense will not be covered under an insurance plan.
The appeal letter is used to challenge the reason stated why. The purpose of an insurance appeal letter is to request money that has already been deposited with the insurance company, either as a refund or as a claim.
Essential Elements of Appeal Letter
A complete insurance appeal letter must include the following essential elements to be relevant:
- Current date
- The sender’s name and contact information
- The policy holder’s name, contact information, and policy number.
- The purpose of writing the letter
- The matter regarding which a benefit was denied.
- The reason cited on the denial notification letter and the letter’s date was received.
- Closing remarks
How to Write an Appeal Letter?
Starting an insurance appeal begins with drafting an insurance appeal letter and submitting it to your insurance company. Use the following guidelines to create your appeal request:
1. Start with the basics
The first thing in your appeal letter is all the necessary details the insurance company needs to identify your case. Start your letter by stating your full name. Follow this up with the policy number. Further, state your contact information, including telephone, email, and mailing address.
After this, state the purpose of writing the letter and present the matter regarding which denial was issued, the reason cited on the notification letter for the denial, and the date the letter was received. The health care provider’s name and contact information should also be included (in case of medical issues).
2. Include details
After presenting the apparent facts about the case, begin your argument about why you believe your policy covers the expense and the denial be overturned. The first argument to present is a direct reference to the section or sentence in the policy that states eligibility for the requested coverage. Be very particular about wording, as the words used on the policy must correlate with the description of the expense to be covered.
Upon establishing that the wording on the policy does indeed support your claim, the following argument is to include a professional opinion. This can be a written statement from a doctor or healthcare provider (if it is a medical case) explaining why a particular procedure is/was necessary for medical matters.
If the provider wrongly stated the service description for which coverage is being requested, the correction should be included in this statement. It is vital to go straight to the point in the insurance appeal letter, but all relevant details relating to the denied claim should still be present.
You can also back up your case with records of past similar or identical expenses that have been covered under that same policy.
3. Send your letter
The final action is to send your insurance appeal letter to the insurance company. Make a copy of the letter and all other documents before sending it. Choose a transmission method based on what the company accepts, either fax or snail mail. Upon sending, keep evidence of successful submission.
If the letter is sent through the mail, use certified mail and obtain the return receipt. You should receive a confirmation notice after your appeal request has been received in about ten days. If not, contact the insurance company and inquire about the letter.
Samples of Insurance Appeal Letters
Here are two samples of insurance appeal letters to guide you while drafting yours.
Insurance Appeal Letter Sample 01
12th April 2022.
343 Promise Ave
Wellson City, NY 12345
Chuck James Miller
23 Page Lane
Wellson City, NY 12345
Member ID XXXXX
The reference number on the explanation of benefits XXXXX
To Whom It May Concern,
I, Chuck James Miller, member ID XXXXX and policy number XXXXX, wish to submit an appeal regarding a denial of a claim by Oathkeeper Insurance to pay for my appendix removal surgery. I received a notification of this denial on the 11th of April, 2022, stating that the procedure was not covered under my health plan because the surgery was an unnecessary medical expense.
As presented in my enclosed medical records, I was diagnosed with appendicitis on the 9th of April, 2022. The inflamed appendix has been a constant source of daily pain and discomfort. I am currently a patient under the care of Dr. Franklin M. Bryce at the New Saints Hospital in Downtown Wellson. Attached with this letter is a Letter of Medical necessity from Dr. Bryce explaining the procedure and why it is essential for my physical well-being’s continued security.
I ask that the documents enclosed with this letter be reviewed regarding my appendicitis surgery and reconsider the previous decision to deny the claim. Please, do not hesitate to reach me at 555-111-3433 if you require further information from my end or Dr. Bryce at 555-222-5644 regarding the treatment procedure. I eagerly await your response.
Insurance appeal letter sample 02
26th July 2022.
Mr. James Horton
Appeal and Grievances Division
Faith Insurance Agency
124 Main Street
Culver City, NY c
Cheryl Lilian Taylor
Member ID #XXXXXX
68 Fleece Street
Culver City, NY 35463
Policy Number XXXXX
Dear Mr. Horton,
I am writing this letter to request an appeal of the decision to deny coverage of the expense of my breast reconstruction surgery. I was notified of the denial by mail on the 22nd of July, 2022, with the reason cited for the denial being that the surgery is purely cosmetic.
Genetic testing and a history of breast cancer in my family confirmed that I am at a high risk of developing breast cancer due to an inherited genetic mutation. As clinical practices and evidence-based research put forth, the best course of action is preventative methods that lower cancer risk. Following consultation with my doctor, Dr. Emmanuel O. Philip of the Full Health Hospital in Culver City, a bilateral mastectomy was recommended and subsequently carried out to secure my health.
Breast reconstruction surgery is a necessary next step to restoring my quality of life and body image. As a requirement under law for medically required mastectomies, my health plan is to cover all aspects of the reconstruction surgery, including any physical complications during any stage of the mastectomy. My surgeon, Dr. Philip, has issued a statement attached to this letter on the high success chances of this procedure and the very positive physical results.
Please, I ask that the earlier denial of my claim be reconsidered as the documents attached with this letter illustrate the detail. I can be reached at 555-124-5346 if needed, and so can my doctor at 555-234-6837. A speedy review of this appeal will be highly appreciated.
Going up against an insurance company can seem intimidating, so we have compiled a list of tips that will significantly improve your chances of claiming the benefit you deserve through the insurance appeal letter:
Bear in mind that the appeal issue might take a while to resolve. The first hurdle will be the confirmation of the letter submission. The insurance company will issue an official notice to you confirming the receipt of the appeal letter. This can take up to ten days from the time of submission. The review process can take some time, but it must not exceed 30 days. After a decision has been made, a notification letter will be delivered to you about the outcome.
Don’t back down
After appealing and still being denied, do not give up yet. There is an option under the Affordable Care Act that allows for a request for an independent external appeal for medical matters. This new review process will be conducted by a third party rather than the insurance company.
Be concise and clear
In every step of your appeal process, present your case clearly and accurately, specially while writing the insurance appeal letter. Have a clear understanding of the matter in controversy and how it applies to your policy. For medical matters, speak to your doctor about the treatment procedure and its chances of success. Finally, present your case with definite facts and professional opinions during the appeal process.
Just because you’ve been denied a benefit doesn’t mean you should take it lying down. Instead, fighting for what you rightly deserve is what you should do, and an insurance appeal letter is the best way to do that. When presenting your case, be backed up by facts, be confident about what you are requesting, and don’t give up until you get your due. Safeguard your health today with an insurance appeal letter.