Health insurance companies often deny claims for treatments and procedures that they consider medically unnecessary or unprocessed, for example, due to factors such as incorrect documentation, errors in the information, etc. Such denials are usually caused due to inadvertent errors made by the patient during the initial application process. In some cases, these denials are apparent, but it can be challenging to get the claim approved.
Some mistakes will inevitably be made, but you have a right to appeal such a health insurance claim denial through an appeal letter and fight for the proper treatment. Below is a guide on what to do when appealing for the health insurance, items to include in your appeal letter, including a sample letter for appealing a health insurance claim.
Tip: Denied claim v/s rejected claim
A health insurance claim can be denied or rejected, two distinct technical terms in the insurance sector. Denial implies expressed disapproval of the claim. This means the insurer will not cover the requested payment. Rejection infers that the claim was not processed due to specific reasons such as paper mix-up, insufficient details, paperwork error, rules not followed, etc. As a result, claim rejections are easy to correct than denied claims.
Common Reasons for Denial of the Claim
There is no shortage of reasons why insurance claims can be denied. Insurance companies are businesses whose intention is to make profits and will often find ways of doing so, insurance claim denials being one way to do so.
Some of the common reasons health insurers will deny your claim include:
Not medically necessary
Health insurers typically approve medical claims that are deemed medically indispensable or compulsory. As a result, any unnecessary, unjustifiable, or unjustified medical treatment or procedure will ordinarily not be covered. Therefore, an appeal letter appealing the health insurance claim would not be enough to overturn such a denial.
Experimental treatment
The health insurance company is not obligated to cover treatment or procedures outside of the benefits you have paid through your premiums. Thus, the health insurance company will deny coverage if you seek any experimental or recommended surgeries that do not fit within the benefits you have paid through your premiums. However, experimental treatment can be covered if it satisfies the following criteria:
- If it can be proven that the experimental treatment is the only medical intervention that will work. However, you must show other treatments that were administered and didn’t work.
- If deemed a standard treatment within the medical community, the procedure will be covered.
- It can be paid for if the treatment is less expensive than standard treatment procedures.
- The procedure will be covered if the health insurer has covered it for the same patient in the past.
Out of network
In many cases, health insurers will only cover treatment from doctors within the network of the clinic that you have signed your contract with. Therefore, you may be denied the claim if a claimed service is provided out of network. This can often be avoided by ensuring that all services are provided within the network.
Health care settings
It is essential to be careful with the health care settings where you have been admitted. If it is a hospital, then ensure that all services are provided within the hospital. If it is an out-of-network clinic, ensure that all services are provided through clinics where you have paid your premiums. If the doctor recommends in-home services or treatment, then ensure that the cost of such services is lower than hospital-based care to ensure your health care plan covers them.
Cancellation of the policy due to lack of money
Health insurers will often cancel your policy if they find out you cannot afford the premiums. Unfortunately, what usually happens is that the insurance company will cancel your policy and, as a result, refuse to pay any claims incurred from that point on. To avoid such an incident, make sure that you pay all future premiums no matter what happens in life or work and notify your insurer of any errors and changes in payments, for example, an account change.
Pre-Consideration
Before you write your appeal letter against the denial of a health insurance claim, it is essential first to consider and evaluate the reason for your claim. This means that you need to ask yourself whether the company has a legitimate reason for denying your claim, such as the procedure is not covered by the health insurance policy. If yes, you can move on to the next stage as an appeal wouldn’t reverse the decision. If no, then deal with the reasons for denial before proceeding with the appeal. Notice of insurance claim denial will typically be sent detailing the deadline for appeal and the reason for denial.
What to Include?
An appeal letter appealing a health insurance claim denial should be direct to the point. It should thus cover the specifics and facts and make a professional, convincing appeal. The specifics will ultimately vary from one situation to another. However, regardless of the situation, ensure the appeal letter covers the fundamental details for appealing against a health insurance claim denial.
A letter for appealing a health insurance claim should include the following:
Opening statement
Start with an opening statement that indicates the reason for submitting the appeal. Suppose the appeal letter is appealing a health insurance claim that is believed to be an error on behalf of the insurance company. In that case, it is better to state this in the opening statement as, in most cases, the claim will be approved if it was indeed an error on their part. Avoid making general statements such as “permission was refused” or “the claim was denied in error.” Instead, cite the specific reason for denial and utilize details and information gathered and collected to support the claim. The letter’s opening statement should be direct, professional, and honest.
Health condition of the patient
The patient’s health condition is the following vital information to be included in the appeal letter against the denial of a health insurance claim. The letter should indicate a cure or an effective treatment to help the patient recover from the illness. It is crucial to note that the insurance company will only cover treatments and procedures that are medically essential. Thus, it is imperative to explain why the surgical procedure was deemed medically necessary and how it relates to the associated health condition. The letter can also state the services rendered for the claim and include details of all expenses incurred due to treatment.
A doctor’s supporting note
Doctors’ notes are essential, especially in appealing health insurance claims. Ensure the letter for appealing the health insurance claim has a supporting note from an experienced or respected doctor who can attest to the patient’s condition. The supporting doctor must have first-hand knowledge of the patient condition, not just a second-hand opinion. It is essential to include all details about your treatment, including test reports, diagnosis, and prognosis.
A list of any medical, legal, or professional medical specialists, the claim form, and any supporting documents submitted by the patient (appeal form) can be referenced in this section. A good appeal letter for appealing the denial of a health insurance claim should be very detailed so that the company can easily understand the situation to help them conclude whether you deserve it or not.
Letter for Appealing a Health Insurance Claim Denial
Sample
[Insurance holder’s name]
[Policy holder’s address and phone number]
[Date]
[Name of the healthInsurance Company]
[Contact information for Insurance Company’s appeals department]
Dear Sir/Madam,
I am writing to ask [INSURER NAME] to review my claim for medical expenses incurred as a result of a motor vehicle accident on [Date] at [Location].I am appealing this denial based on a medical necessity.
Before the accident, I was driving out of my subdivision when my car was hit by another vehicle. My husband and I were both injured in the collision and had to seek medical treatment. I had my surgery to regain my health and the full range of motion. Unfortunately, a copy of the x-ray, an ultrasound, and an MRI shows my bone is healing poorly and will only worsen without surgery. The doctor said he’d seen this problem before in patients who waited too long to have surgery.
I’ve already tried physical therapy with [provide the name of doctor or clinic], who said she does not see improvement in my condition every time she works with me. Her note is also enclosed. I’m sharing two letters from my doctor and another from my physical therapist here. I’d appreciate it if you’d look over the documents I have provided and take appropriate action regarding my claim.Please pay for this procedure so that I can get back to being active again.
In the absence of your intervention, my medical condition is expected to deteriorate and might require further procedures, which are more expensive. Therefore, I would like you to reconsider this matter and let me know if you have anything I should include in the appeal.
Sincerely,
[Signature of the policy holder]
Free Sample Letters
You can download free sample letters given below:
Frequently Asked Questions
A survey conducted in 2019 on insurance companies that work with HealthCare.gov indicates that an estimated 17% of all their in-network claims were denied. However, 1-50% of health insurance claims with independent insurers were denied. The survey also noted that catastrophic plans are more likely to be denied with an average rate of 20%. It was also noted that insurers who work with Healthcare.gov are more transparent about their denials.
A survey conducted in 2019 on insurance companies that work with HealthCare.gov indicates that an estimated 17% of all their in-network claims were denied. However, 1-50% of health insurance claims with independent insurers were denied. The survey also noted that catastrophic plans are more likely to be denied with an average rate of 20%. It was also noted that insurers who work with Healthcare.gov are more transparent about their denials.
Affordable health insurance is always a priority for everyone. Individuals can get affordable healthcare through their employers or government-initiated programs such as state-initiated health insurance such as Medicaid. Always strive to understand the terms of each policy before enrolling to ensure you apply for a health care policy that befits your income and financial ability.
