Health Insurance: Claims: Appeals: Sample Cover Letter
Following is a sample generic letter to appeal denial of a health insurance claim. If the denial relates to a claim by the insurer that the treatment, procedure or use of a drug is not "medically necessary", see: Health Insurance: Claims: Appeals: Medical Necessity. If it relates to a request for a second opinion, see: Health Insurance: Claims: Appeals: Second Opinion.
XYZ Insurance Company
1234 X St.
Sunderson, PD 00000
RE: Cathy Rockett, Dependent of Employee, John Rockett
Social Security No. xxx-xx-xxxx
Group No. 00000-00
Claim No. 00-00000-000-00000
[Summarize why you are writing. For example:]
I am writing to appeal the denial of my claim for ___________ performed by Dr. Whaley on June 14. See attached Explanation of Benefits ("EOB") denying claim.
[Provide a history of the situation, including a description of your medical condition, the current situation and why you are requesting the treatment, procedure or drug. For example]
As you are aware, I have xxxxxxxxxxxxx (medical condition). Your EOB form states that the request for (name of treatment, procedure or use of a drug) was denied because it was outside the scope of your coverage. I spoke with Helen Trent in your Claims office on August 10 and she said that your rules only allow covering those treatments once a month and I was having the treatments weekly.
[Insert the provisions of your policy that you think means what you want should be covered. For example:]
Please note the following provisions of the subject insurance coverage which covers this procedure:
"[Quote the wording from the policy that covers the procedure, treatment or use of drugs you desire.]
[Describe any exclusions that could relate to your situation and explain why they are not applicable. For example:]
There are no applicable exclusions in the policy which would deny coverage.
[Explain why what you want is necessary. For example: ]
While monthly may be an average for the treatments, my condition is severe enough that weekly treatments were necessary for me to get any benefit at all from them.
[Attach a letter from your doctor explaining why you need the treatment, procedure or use of a drug- and mention it in your letter. For example:]
Attached is a letter from my doctor explaining the medical necessity [use the insurance company's terms in your argument as often as possible] of weekly treatments.
[Attach articles and other materials from noted medical sources which confirm use of the treatment, procedure or drug in your medical situation. For example:]
Also attached is an article from The Journal Of The American Medical Association that discusses the need for greater frequency in treatment in certain cases, such as mine.
[Explain what can/could happen to you if you don't receive the requested treatment, procedure or drug.]
FAILURE TO PROVIDE IMMEDIATE TREATMENT FOR MY ILLNESS WILL CAUSE AN IMMINENT AND SERIOUS THREAT TO MY HEALTH.
[If the treatment is something you've had in the past and should be continued, explain why. For example:]
Finally, when I first started these treatments, which you will see in the medical record, we started them monthly for two months, but there was no improvement in my condition at all. However, once the doctor started weekly treatments, the improvement has been dramatic and the pain has almost completely gone.
My doctor and I both think that once this series of treatments is finished I should need no more than one every three to six months. The frequency of treatments has worked wonders for me so if improvement of the medical condition is any indication, the weekly treatments were truly medically necessary.
[Request an answer in a short period of time such as seven days from receipt of the letter - or the time described in the insurer's appeal procedures. If you need the procedure, treatment or drug immediately, and there would be harm to your health if you don't get it right away, ask for an Expedited Review. For example:]
PLEASE PROVIDE AN EXPEDICTED MEDICAL REVIEW OF MY APPEAL. PLEASE PROVIDE ME WITH A DECISION AS SOON AS POSSIBLE AND NO LATER THAN FIVE DAYS FROM THE DATE OF THIS APPEAL.
Please review and cover the charges you originally denied and get back to me within seven days of the date of this letter.
[End on a polite note. For example:]
Thank you in advance for you prompt attention to this request.
Very truly yours,
[Keep a copy of the letter for your files. Send the letter in such a manner that you receive a receipt proving it was received and who signed for it. For example, by overnight service or by U.S. Mail, Return Receipt Requested.
Keep track of dates and follow up to be sure your complaint is moving forward quickly. Keep a record of all communications, including the date and time of your conversation, the name, title and direct phone number of the person with whom you speak, and a summary of the discussion.