I recently published an article on what to do when an insurance company denies your claim. I had mentioned that one of the first things you can do is write a letter of appeal to the insurance company. What I did not include was how to write such a letter. So I figured I would use the letter that I wrote as an example. Of course I am going to change some of the details like my insurance information and things like that. Regardless of the things that are changed I think you should pretty much get the idea of how you should write this.
After you have written a letter of appeal you should also make sure that you mail it certified so that it requires a signature. One problem that people seem to run into when trying to resolve certain issues via the mail is that certain companies often claim that they never received such a letter. Mailing it certified not only allows you to track it and see when they received the letter, but also who signed for it. It may cost a little extra money to send it out that way, but it’s definitely worth saving the hassle that can come about if you have no proof that a company received your letter
Here is an example of what I wrote as a letter of appeal to my insurance company:
July 25, 2007
My insurance Company Representative
Name of my insurance
Insurance companies street address
City, State, and the zip code
Re: Request for reconsideration of coverage denial.
Jill Ermer
My insurance name PPO
ID# ABC0000D0000
Bin# 123456
Dear Sir or Madam,
After receiving a bill from Blank Radiology Associates LLC I have decided to appeal your decision to deny coverage of my recommended treatment plans for both my CT Thorax w/dye on June 11th and trans-vaginal ultrasound on June 4th.
In the billing code 10 (per your insurance carrier, theses services were not medically necessary. Payment was denied) was given for cat scan w/dye done on June 11th at Blank Hospital in Buffalo NY in which treatment was ordered by Dr. Jane Doe. Also code 11 (per your insurance carrier these services were for a pre-existing condition. Payment was denied) for my Transvaginal ultra-sound performed on June 4th ordered by Doctor John Doe at Blank Hospital in Buffalo NY.
On June 11th I entered the emergency room at Blank Hospital suffering from severe chest pains and an inability to breathe. Due to the fact that I have been diagnosed with not one, but two blood clotting disorders the risk of having a potentially fatal blood clot in my lung was highly suspected. In order to properly diagnosis if I had a potential deadly blood clot a CT Thorax w/dye was absolutely necessary. I know this because I was not only approached by a specialist but I was also counseled by the hospital administrator and a religious counselor. In which they made it absolutely clear that if I did not have this procedure death was an extremely high risk. If I had a blood clot in my lungs as it would travel to my heart and kill me instantly. To deem this procedure as medically unnecessary is not only an issue of legality but it is a moral issue as well. Basically I view this determination as a lack of compassion as to whether or not a client dies. I hope that this is not common practice because I don’t think the State Medical Board nor the Attorney General would agree with it. I don’t mean to sound hostile but such a code given is very discerning as it makes me feel as if my life has no value what so ever.
For the Transvaginal Ultra-sound performed on June 4th I am some what baffled as to how a miscarriage is a pre-existing condition. A miscarriage left undiagnosed can also lead to death if there are certain complications with in the uterus. I would need further explanation as to how myself or the Doctor were supposed to know if I was having a true miscarriage without proper procedures to accurately determine if that was the case. In some cases of miscarriage a D&C is required to help stop uterine bleeding as a woman could die from slow hemorrhage. To perform a D&C without an accurate determination that a miscarriage is taking place is illegal as it is considered abortion if a miscarriage was only based on assumption. I don’t understand how my miscarriage can be considered pre-existing when all my prior prenatal visits indicated no such thing.
I look forward to hearing from you soon on the regards of your decision.
Sincerely,
Jill Ermer
My street address
My city, state and zip code
My email address
Phone number(home)
phone number(cell)
Remember this is just a letter of appeal, it does not guarentee that the insurance company will change their decision regarding medical coverage on a procedure or treatment. It is best to make sure you have a lot of sufficient evidence that will back up the necessity for the reason that a medical procedure or treatment was performed.
If you have been denied coverage for a major medical problem that has resulted in thousands of dollars worth of medical bills you might want to have a lawyer write your letter of appeal. A couple hundred dollars in lawyer’s fees is definitly worth it if you have a large amount of medical debt. Having a lawyer write such a letter really shows the insurance company that you mean business.
