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Appeal Letter for Health Insurance Denial

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Insurance companies make a number of excuses when they deny coverage –they’ll say the procedure is not medically necessary, the procedure is experimental or is not generally accepted in the medical community, there is a cheaper, better alternative, etc.–but what insurance companies really care about is their bottom line. When they deny you coverage for treatment, it is because they are trying to save themselves money. Their reasons may be legitimate based on the policy, or they may be bad faith reasons, thrown together to justify denying treatment that should be covered.

When you are wrongfully denied coverage for your medical care, you have the right to appeal. One of your first steps when fighting a denial is to send a letter to your insurance company appealing the denial of your coverage. Read on for tips on how to write an effective appeal letter for a health insurance denial, and reach out to a passionate and dedicated Los Angeles insurance denial lawyer if your insurance provider wrongfully denies you coverage for medical care.

Identify the specific reasons your claim was denied

To write an effective appeal letter, you must address the precise reasons your claim was denied. Some of the most common reasons insurance companies use to deny coverage include:

Your treatment was excluded from the policy or off-plan
There were errors in the claim documents such as incomplete or missing information, or medical billing errors such as using the wrong code
Your treatment was medically unnecessary, experimental/investigative, or purely cosmetic
You exceeded your coverage limits
You used out-of-network services, including using your plan outside the state covered

Your appeal letter should address and target the specific reason given for denial or rejection. If the insurance company’s notice of denial did not give specific reasons for their decision (which it must do pursuant to California law and your policy), you would need to talk to your insurance company to find out the details. Your insurance denial attorney can handle the communications with the insurance company to ensure you get all the information necessary to properly request an appeal.

What to include in your appeal letter

Your appeal letter should be short and to the point, including the information necessary to identify your case. It should identify the reasons for your denial and should concisely refute those reasons. It should concisely explain what the treatment is, why you need it, and why it is covered.

Your letter should generally include the following:

  • Opening statement. Your opening statement will include your identifying information (name, policy number, claim number, denial information). It should include why you are writing, what treatment or service was denied, the reason for the denial, and the fact that you are seeking to appeal.

  • An explanation of your medical condition, medical history, and the specific health problem at stake. Your letter should explain your circumstances, why you need the treatment, and why you believe it is appropriate (medically necessary, established in the community and not experimental, etc.). If you have tried other treatments, list those as well to show why the current treatment may be the solution.

  • Supporting documentation. Include letters from your doctor, medical records, and other supporting information that shows the services you seek are part of a recognized treatment plan.

Strategies for writing an effective letter

In addition to including the information above, here are a few tips to writing an effective letter:

  • Co-author letters from your doctor. If your argument is medical necessity, for example, draft a letter explaining your need for the procedure and its effectiveness, and then send the draft letter to your doctor. Your doctor can then edit the letter as necessary and put it into their letterhead. This will significantly speed up the process and help your doctor quickly understand your case and the issues at stake. They have a lot of patients, and it is easy for your request to get lost in the shuffle.

  • Attach all of the medical records that would support your appeal, and reference those documents in your letter. Attach other communications with the insurance company as well, including their denial letter.

  • Explain why your coverage will save the insurer money. Your letter should explain why paying for this procedure now will save them money later by avoiding future hospitalizations and costly, ongoing treatments.

  • Write clearly, concisely, and with as many medical terms as possible. Proofread. You want your letter to appear professional, well-informed, and accurate. Your attorney will help you draft the clearest, most professional, and effective letter.

Help is Available After Your California Health Insurance Claim is Denied

If you’ve had a claim for benefits rejected by your California health insurance provider, get seasoned and reliable help appealing your claim denial by contacting the Los Angeles insurance claim denial lawyers at Gianelli & Morris for a free consultation at 213-489-1600.

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