How can I make my insurance appeal seem more convincing?

Question

What can I add to my health insurance appeal form, to make it more convincing? I have a feeling they are going to reject my appeal so I want to sound confident and, if you will, intimidating.

Answer 1

Not knowing the specifics of your case, I'll give you some general help:

Since insurance companies are generally stupid, the easiest way is to break it down into dollars and cents. Show them that by paying for this procedure now, it will more than likely save them ten times as much if a complication arising from not having the procedure done comes later on. Since I don't know the specifics of your issue, I'll give you this as an example:

Many insurance companies give a hard time about paying for the Gardisil (HPV) vaccine. However, if there's a family history of cervical and uterine cancer at a young age in the patient's family, it's more cost-effective for the insurance to shell out $500 now for the vaccine, rather than thousands later for cancer treatment. Therefore, it's in their best interest - both medically for the patient, and financially for the insurance company - to pay for the preventative.

That said, if you're trying to appeal for a non-covered benefit, you need to prove that it's VERY medically necessary - and provide as much documentation as backup as you can get. If you're trying to get approval for an out-of-network doctor, you either need to be able to show that there is no one in-network within a certain radius of you, or that this provider does something so specialized that no one in network does it. BUT, if it's something absolutely not covered (like cosmetic surgery, for example) you can't beg, plead, or force them to cover it. All you can do is exhaust all your options.

Good luck! (And don't get frustrated easily - insurance companies count on p*ssing you off, so maybe you'll pay the claim, so they don't have to. That's why it's not easy.)

Answer 2

The BEST way to write a persuasive appeal is to quote from the insurance policy. You may want a claim paid, but if the policy doesn't support payment, it doesn't matter how aggressively the letter is phrased.

You may also consider calling your state's insurance commissioner's office and asking whether there are any state laws you should be aware of. Tell them the reason(s) the claim was denied and ask for specialized advice.

Answer 3

In order to win your appeal, you should state the rule or regulation that was violated when your insurance claim was denied. That is the only way to be convincing and for your appeal to be granted. Resorting to the use of intimidating words will not do you any good. You will only hasten the dismissal of your appeal.

Answer 4

If you have to add things to make your insurance appeal more convincing, then you are not telling the truth and that's insurance fraud.

Answer 5

Letters from two different doctors describing why the item is/was medically necessary, and why it's standard procedure.

You effectively need to refute the declination reason, with something besides emotion.

Answer 6

pretend you are a stockholder

maybe actually buy a share of stock

then raise that issue at the shareholder meeting