There are several reasons a health insurance company may deny a claim. If a patient believes their claim was unfairly denied, they can write a reconsideration letter to the insurance company to ask for their claim to be reevaluated. In order to succeed at getting a reversal of a claim denial, the patient must consider the insurance company’s perspective. The most common reasons a claim is denied are:
• The information on the policy is incorrect or missing. If the health insurance company has the wrong information or needs more information to approve the claim, providing the required information can result in the denial being overturned.
• The benefit required by the patient is not covered in their plan. The insurance company is only required to give customers the benefits for which the customer paid. If the plan is not comprehensive enough, the customer needs to add more treatments to the policy.
• The patient has a pre-existing condition that he or she knew about and received prior treatment for, before they joined the current health insurance plan. The insurance company knows it will most likely have to pay for treatment of a pre-existing condition. Even if they charge the customer more, it may not cover the cost of treatment. In order to make money, the insurance company raises the premiums of other policy holders.
• Claims for treatments that are not medically necessary are often denied. This means the treatment is not for an illness, disease or injury. Treatments must be generally accepted standards of medical practice and be clinically appropriate and effective.
If the patient wants the claim denial to be reconsidered, they should understand that the process may be long and they will need to gather a lot of information and documents related to their medical expenses. The first step in the process is to get the reason for the denial in writing from the insurance company. The denial letter will include an offer to send the patient a copy of the entire file that includes their internal clinical criteria. The patient should send a letter requesting the file, and if it doesn’t arrive within 30 days, they can call the insurance company and inform them that they have requested the file.
Next, the patient should gather all the medical documents pertaining to his or her treatment including test results, surgical reports, hospital discharge summaries and more. The patient needs proof of his or her diagnosis, the history of the illness or injury and a list of the treatments. If the insurance company denied payment because the treatment was experimental, the patient needs to include medical journal articles by doctors that show the treatment is effective.
Now the patient is ready to write the reconsideration letter. The patient should follow the appeal procedures outlined in their insurance policy. If the guidelines are not in the policy, the patient should call the insurance company and ask for a copy. The reconsideration letter may include:
• The policy plan and approved treatment information
• The policy number
• The treatment dates
• The total medical costs from doctors and hospitals
• The reason the insurance company gave for the denial
• The patient’s intent to appeal
• Any specific records mentioned in the denial letter
• The required records for claim approval
• Additional information and a request for a review of the claim with the updated information
• The patient’s contact information
This is a sample of a reconsideration letter to a health insurance company. It is recommended that the letter be a formal business-style document and sent by certified mail. A copy of all of the correspondence with the insurance company should be kept by the patient.
Sample Reconsideration Letter
Name of Patient
Address of Patient
City, State, Zip Code
Policy Number of Patient
Name of Claims Director
Name of Insurance Company
Address of Insurance Company
City, State, Zip Code
RE: Appeal for reconsideration of a medical claim denied to Name of Patient, Policy Number.
Dear Name of Claims Director:
This is a formal appeal letter for the denial of my claim for TREATMENT. I received the denial on DATE and the following reasons for denial were given:
The physiotherapy for my injured knee was experimental therapy and not clinically approved.
I am appealing the denial because my doctor recommended the therapy for my injury. It is an innovative treatment and considered very effective by osteopaths and physical therapists.
I have enclosed three articles in the New England Journal of Medicine that were written by experts in the field of sport’s injuries, who state that this treatment gets the best results for knee injuries than any previous treatment. I have also enclosed a letter from my doctor stating that this treatment was required for my injury.
Please reconsider your denial of payment for this treatment. If you need any further information about the treatment or from my doctor, I would like a request in writing. You can reach me at the above address or at Email Address.
Thank you for your time and consideration of my request.
Signature of Patient
Printed Name of Patient
List of Enclosures: Medical Documents, Bills, Articles and Letters from Doctors
By Andre Bradley