This is an Appeal Letter written by an individual displeased with the insurance company’s decisions regarding the processing of an insurance claim.
The appeal letter is meant to give you an opportunity to seek a review of the decision by the health insurance company. The aim of writing this appeal letter is to try and set up a meeting for further negotiations with the insurance company. With a meeting in place, you can address the terms and conditions of the agreement and get the insurance company to change their decision about not covering your medical costs. It is essential to include your contact details in your appeal letter to make it easier for them to contact you to follow up on your appeal.
A proper appeal letter to the insurance company can significantly increase the chances of the final decision to be in your favor. Before you write that appeal letter, make sure that you have reviewed the state laws to determine the coverage expected from health insurance companies in your State. After you have confirmed the coverage you should receive from your health insurance company; you can proceed to write the appeal letter to the insurance company.
Steps for Writing an Effective Appeal Letter
An appeal letter is formal and must follow the official business letter format. With the steps provided below, you can adequately write an appeal letter to the insurance company using the proper format and the required details:
1. Start with the basics
The first part of your appeal letter is about the basic details of your issue to help the insurance company to understand your appeal. You should include your name as it appears in your health policy, the policy number on the insurance card, the policy holder’s name, your contact details such as phone number plus mailing address, and the health care provider’s name plus their contact details.
You also need to include the date of denial, the details of what was denied, and the reason for this denial. Finally, if you are writing the letter on behalf of someone, ensure you include the patient’s name.
2. Include details of the case
It would be best if you had body paragraphs containing a detailed explanation of the medical situation. Your information should be specific and include all details related to the situation, and provide all the necessary information that will propel the insurance company to change its verdict to a positive one.
Brief introduction
This will include your full name, age, primary diagnosis, description of the claim, and why you believe the insurance company handled your claim unfairly.
For example,
I am Kevin Henry, 55 years old. I was diagnosed with heart failure that resulted from blocked arteries. I need heart bypass surgery, and your insurance company denied my claim. Therefore, I am writing this letter regarding claim number 54000, where my claim was deemed not medically necessary. However, this is to inform you that the surgery is essential to reduce the frequent hospital trips required to manage the condition. In addition, the surgery is way cheaper than any other medical procedure.
Description of medical conditions
The next step is to provide a detailed description of your medical conditions and the relevant medical procedure or item that you need.
For example,
My heart failure diagnosis results from the obesity that I am currently struggling with. I have been in a program to help me deal with this condition. However, due to my obese condition, I tend to have frequent hospital trips to help manage my condition. The danger of heart attacks and strokes is always present in my health condition which will further complicate my situation and affect my quality of life.
Explain the importance
You should then explain the benefits you will get from getting the medical procedure or item.
For example,
With the heart bypass surgery, I will be able to reduce costly hospital visits due to coronary angioplasty aimed at unblocking my arteries. The surgery will improve my health allowing me to lead a more active lifestyle helping me with my obesity. With a healthy heart, I can quickly lose weight and avoid the threat of a stroke or heart attack.
Follow by mentioning what will happen if you do not receive the medical item or procedure and highlighting how costly it will be.
For example,
If the verdict is not changed and I cannot receive my heart bypass surgery, my hospital visits will increase due to my blocked arteries. This might lead me to stay at the hospital for an extended period and require more medical attention due to higher risks of heart attacks, strokes, and even kidney failure. All this together would lead to higher medical costs as compared to the costs of the heart bypass surgery.
Attach medical records
Ensure that you attach your medical records in a way that is easy for the insurance company to understand. You can also support your claim by providing more details of your medical condition through brochures, published research articles, and treatment guidelines by various medical organizations.
Close the letter
Summarize your arguments by highlighting the most crucial appeal detail.
For example,
To avoid further hospitalizations, I should receive my heart bypass surgery as soon as possible. Once I have recovered , my heart bypass surgery reduces the chances of any other costly procedures or lengthy hospital stays.
Express your gratitude at the end of your appeal letter to the insurance company.
For example,
I am grateful for your time and consideration of this sensitive matter. Thank you very much.
The final part of the letter includes a complimentary close and signing of the appeal letter.
Sincerely,
(Signature)
3. Ensuring it reaches the recipient
The final step of writing your appeal to the insurance company is to ensure that it is sent to the correct address and on time. Whether via fax or snail mail (certified mail), ensure that you retain the confirmation message or the return receipt (proof of delivery) until the appeal process is over. Do not forget to keep a copy of the letter for your own records. Â
Template of an Appeal Letter to the Insurance Company
[Your policy number]
[Policy holder’s name (if writing on behalf of someone else)]
[Your full address]
[Your phone number/email]
[Date]
[Name of Insurance Company or Health care Provider]
[Full address]
[Contact Information]
To Whom It May Concern:
I am writing this letter on behalf of [patient’s name], [age] with a [mention the diagnosis] to appeal against the decision to deny him [mention the claim description]. This letter is about [include the claim number] where the [explain why the insurance company is wrong for denying the claim].
[Patient’s name] has [explain the diagnosis] for a while, and it has led to [provide a detailed description of the medical condition]. His condition will significantly improve if he receives [explain the denied medical procedure or item]. Ensuring that there is no further delay of treatment of his [mention the condition] will significantly improve his health by [explaining the benefits the patient will get from receiving the medical procedure or item].
If this appeal does not go through, [patient’s name] will experience [explain what will happen if the patient does not receive the medical item or procedure]. In addition, further delay and failure of treatment by denying him the [mention the medical item or procedure] will lead to [highlight all alternatives that are present], which are likely to be [highlight the costly nature of the alternatives compared to the medical item or procedure needed].
Below are all the necessary documents [attach the patient’s medical records] that will be needed to corroborate the medical facts of [patient’s name] case. I believe that providing [name the medical item or procedure] will significantly contribute to [highlighting the appeal’s most crucial detail]. Thank you so much for [appreciate your gratitude for their time and consideration].
Sincerely,
[Signature]
[Your name]
Appeal Letter Samples
Nine Essential Strategies to Ensure Success with Medical Claims
When writing an appeal letter, there are nine essential strategies that you can use to ensure that the insurance company deals with your claim fairly. Observing the following strategies will help you write a proper and effective appeal letter to increase your chances of getting a favorable new verdict.
Here are the nine crucial strategies you should use when writing your appeal letter:
Draw attention to financial benefits
Insurance companies, just like any other organizations, are always interested in making profits. Therefore, when writing your appeal letter to them, your focus should be on showing the insurance company how changing the denial claim will help them save money. The aim is to provide clear and distinct factual examples of how they will benefit from approving the denied claim.
For example, you can highlight that the item or procedure you want them to cover will reduce the number of hospital visits, lengthy hospital stays and other procedures that might be costlier than your original request , which means they will eventually save money.
Check for errors
In some cases, insurance companies might deny your appeal because of the mistakes in your letter. It is, therefore, essential to check for errors and correct them to ensure you have the correct information in your appeal letter. It would be best to avoid making simple mistakes like writing the wrong identification number to avoid having your appeal letter rejected by the insurance company.
Check for spelling and grammar mistakes
Before sending your appeal letter to the insurance company, ensure that you proofread your letter to correct any spelling and grammar mistakes. In most cases, you may need to check if you have correctly used the right format and written the medical terms, names, claim number, and insurance policy identification number correctly. Spelling and grammar mistakes make the letter non-serious and might impact your chances of a favorable answer.
Involve a medical professional
Since it is about your medical situation, it will be good to strengthen your your appeal letter by inviting your doctor or any other medical professional to lend support to your claim. You can write a good letter with the help and support of your doctor. Keep in mind that waiting for the doctor to write the letter themselves might take too long to start your appeal process.
In most cases, the medical personnel is too busy, and the best way to avoid further delay is by writing the letter yourself and emailing it to the doctor to lend his support by adding some information on your medical situation. Ensure that the doctor sends back the accurate appeal letter along with any other required documentation.
Attach medical records (if needed)
If possible, ensure that you attach the medical records, as this type of documentation will support your appeal letter. Apart from your medical records, you should also attach any other medical documentation that supports the claim you have made in your appeal letter.
For instance, you can include a brochure with information about the importance of the medical procedure the insurance company denied you. A copy of the insurance claim denial should also be attached to your letter.
Accuracy and sticking to facts
The insurance company cares more about the case facts than a sob story about your financial situation. So instead of mentioning how sad you are about your health or your financial struggles, try and focus on writing a letter with accurate facts about your case.
Approach the case manager
Most insurance companies have case managers who can be approached, especially if your case involves a child with multiple medical issues. A case manager will help you process your appeal once you have written your letter to the insurance company. In addition, you can send them a photo of your child to keep them motivated when working on the case.
Appeal to the HR department
Another important strategy you should implement when writing a letter to the insurance company is to appeal to the HR department. This is because the human resource department will hold negotiations with the insurance firm and assist you in changing the verdict. So reaching out to the HR department will improve your chances of getting a favorable result.
Look for all possible solutions
In case your internal appeal is denied by the insurance company, you can request an external appeal, according to the ACA. A third party usually conducts these negotiations instead of the insurance company. The health insurance company must inform the third party why your appeal was denied and highlight your rights to an external appeal. Depending on your state, you can also get help from the Consumer Assistance Program (CAP).
Wrapping Up
An appeal letter to the insurance company is a formal letter that will be needed if the health insurance company has unfairly dealt with your claim. This is the first step for starting your appeal process once you have confirmed that the state laws require insurance companies to cover your specific medical item or procedure. Ensure that you follow the steps and strategies provided in this article to write a proper and effective appeal letter.
