Like millions of other Americans, you rely on your insurance policy to pay for essential expenses. Basic medical needs are typically addressed by your workplace health coverage, and treatment for on-the-job injuries falls under a worker’s compensation policy. It can be stressful, frustrating, or frightening to write a letter when an insurer declines to pay for visits to a healthcare provider, necessary medications, or important procedures.Nevertheless, you must be in a rational state of mind to compose an appeal letter regarding its decision. Insurers only regard the facts surrounding your claim as well as the guidelines specified within your policy. Unbridled anger or timidity will get you nowhere and could undermine the clarity of your writing.Instead, use our insurance appeal letter templates to build your message. With our advice on wording your argument and formatting your document, you’ll have a missive that effectively presents your case.
Insurance Appeal Letter Template
In the space below, you’ll see an example of an insurance appeal letter. Scott Ryder is challenging a refusal to pay for a medically necessary examination by his workplace’s health insurance company. Scott worries about his ability to maintain good health, but he keeps a clear head and adopts a professional tone when contesting the insurer’s decision.
Ohio Mutual’s letter of denial for services dated August 14, 2017, specified that it declined a prior authorization request for a mammogram from my physician, Dr. Harry Carlyle, due to a “gender marker mismatch.” In light of Ohio Mutual’s policies and important medical information about me that you may not have possessed at the time, I am requesting an appeal of this decision.
As you are aware, Ohio Mutual’s document “Policy Statement on Services Covered for Transgender Members” states that Ohio Mutual “does not deny or restrict healthcare services ordinarily available to individuals of one gender to a transgender member due to the member’s gender differing from the one for which healthcare services are typically or exclusively available.” Under this statement’s definitions listed in Section D, the “FtM-identified person” classification applies to me. I am 32 years old and have not yet undergone chest reconstructive surgery. Moreover, Dr. Carlyle believes that I will significantly benefit from mammography screening due to the high rates of breast cancer in my family.
To assist you in your review, I have attached a copy of his letter dated August 26, 2017, which explains my medical history in greater detail. Based on Ohio Mutual’s existing policy and the medical necessity for mammography services, I ask that Ohio Mutual reconsider its denial of my physician’s prior authorization request. Please contact me if you require additional documentation or have more questions.
How To Write an Insurance Appeal Letter
An insurance appeal letter can seem tricky to write, but it’s not as hard to craft as you might believe. Its purpose is to persuade the insurer to rethink its decision by presenting a compelling case backed up with pertinent supporting information. You’ll likely address your communication to a case manager, review board, or another staff member charged with reviewing appeals. As the insurance appeal letter template shows, you should stick to a letter that’s no more than three paragraphs in length and focus on the important facts.
In your introduction, reference your insurer’s letters explaining the reasons for declined coverage or the refusal to pay out expected benefits. You’ll also want to state the reason you’re asking for an appeal, tying it to existing policies and briefly summing up documentation proving that you’re covered for the services in question.
The next segment of your missive is where you’ll explicitly argue your case. Present your evidence in a concise and respectful manner, citing specific sections of your policy or other communications issued by the insurer that impact your benefits and coverage. Moreover, refer to statements from your healthcare providers that detail the medical necessity of the treatments you need or that clarify any misconceptions on the part of the insurance company.
Lastly, you’ll finish by referring to any documents you’re enclosing and reiterating your request for an appeal. It’s helpful to mention that you’re willing to supply other information if the insurer needs it. Your final paragraph should also display the same reverential, professional tone you used in the opening and middle sections.
What To Avoid in Your Insurance Appeal Letter
Since the objective of your insurance appeal letter is to request the insurer to reconsider its decision, your document must be intelligible, fact-filled, and professional in tone. For these reasons, it’s prudent to avoid dealing duplicitously with your indemnity company. Insurance fraud is illegal, and you could face both criminal and civil penalties if caught. Emphasize critical information, such as medical reports and your insurer’s policies, and be sure you tie them to an explanation of why you feel the company’s decision was in error.
Of course, composing your letter isn’t just limited to including an accurate, easy-to-follow breakdown of the relevant facts. An all-too-common faux pas is shipping off the letter without reviewing it for grammar and spelling issues. While some insurance company staff or appeals board members might be forgiving of any missteps in your prose, it’s only courteous to read through your message and make any corrections before transmitting it to the appropriate party. A coherent, error-free document allows your audience to understand your argument.
How To Follow-up After Sending Your Insurance Appeal Letter
Assuming you sent your insurance appeal letter within the time frames specified by current federal law, it’s not good to let too much time pass without some sort of follow-up from your end. It’s not a bad idea to phone the provider and ask it to verify receipt of your communication. Also, health insurance regulations will mandate a deadline by which your insurer must render a decision, so use that as a guide to tell you when to expect a written response. Don’t hesitate to call or email your company representative around the deadline to confirm the results of your appeal request. Finally, remember that you may benefit from a quicker turnaround authorized by law if you urgently require the treatment or medication.
Top 5 Insurance Appeal Letter Writing Takeaways
1. Open your letter with an overview of your insurer’s decision and why you’re appealing it
It’s important to establish the facts of your case straightaway. Reference your insurer’s denial of services or explanation of benefits letter and state the reason you’re asking for an appeal.
2. Incorporate a clear explanation of the facts germane to your situation
List any diagnoses from your medical team and other important details. Don’t forget to mention dates and your healthcare providers’ names, especially if you’re enclosing additional documents.
3. Cite information from your insurance company’s policy and related communications
If your insurer should normally cover the services refused to you, refer to any relevant sections of the policy. Feel free to quote directly, or paraphrase and refer to document names and numbers.
4. Attach supporting information with your missive
Be sure you know whether your insurer wants copies or originals, and supply them with your communication. This can include letters from your physician, lab reports, and test results.
5. Keep your approach professional and respectful
While you may feel your insurer’s decision was unfair, it will evaluate your case based on only the facts and its own regulations. Steer clear of slang, slanted or emotional prose, and grammar or spelling errors. It’s wise to proofread your letter before sending it.