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Things to Include in an Insurance Appeal Letter

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If your health insurance provider denies you coverage for a medical claim, you do not simply have to accept their decision. Insurers deny coverage for a variety of reasons, and in your case, their reasoning may be wrong. They may have made a mistake, they may be wrong in their interpretation of your policy or what your treatment entails, or they may have denied your claim for improper reasons in bad faith. You have the right to contest the denial and fight for your right to coverage for the care you need. One of your first steps in contesting a denial of coverage is to write a letter to your insurance provider appealing the denial. Continue reading for a discussion of what you should include in an appeal letter following a health insurance denial, and reach out to a knowledgeable and experienced Los Angeles insurance denial lawyer if your insurance provider wrongfully denies you coverage for medical care.

Brief opening statement

Your opening statement should be brief and to the point, explaining who you are and why you are writing. You will include your identifying information (name, policy number, claim number, denial information). The opening statement should then include the specific treatment or service (past or planned future) that was denied coverage, the insurer’s justification for the denial, and that you are appealing that denial.

Body of the letter: Your argument against denial

The body of your letter should lay out all the facts relating to your case and present a persuasive argument as to why the insurer’s denial was incorrect. It should be brief and to the point but include all the pertinent information. You should include important details about your circumstances, including:

  • Your current medical condition (and its urgency)
  • The specific health problem for which you are seeking treatment
  • The treatment or service you are seeking
  • The insurer’s justification for the denial
  • Why the treatment is appropriate: medical necessity, proof of its effectiveness, proof it is accepted in the community and not experimental, etc.
  • An explanation of your medical history, including other treatments you have already tried for this health issue that have not worked
  • Why the insurer’s justification is incorrect

Utilize a knowledgeable bad faith insurance denial lawyer to help you draft the most concise and persuasive letter.

Supporting documentation

Your letter should include more than a persuasive argument. To succeed in your appeal, you must back up your claims with evidence demonstrating the items that you have included in your letter. Reference the attached documents in the body of your letter. Supporting documentation includes, among other things, the following:

  • Medical records relating to your current condition
  • Medical records showing your medical history, including other forms of treatment you have tried for the current health issue
  • Medical bills
  • Communications with the insurance company, including your denial letter
  • Supportive letters from your doctors and other healthcare providers. You may want to help write the letter for your doctor to make it persuasive and to help remind your doctor of the specifics of your case.
  • Scientific evidence such as studies or journal articles supporting the efficacy or pervasiveness of a treatment, to counter claims that a treatment is too experimental or not widely accepted.
  • Your insurance denial attorney can help you compile the documents you will need to attach and ensure that you include the documentation necessary to make the most persuasive argument.

Call for Help After Your California Health Insurance Claim is Denied

If you’ve had a claim for benefits rejected by your California health insurance provider, get passionate and effective 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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