Sample Letter: Appealing a Medical Insurance Claim That Was Rejected
Certified Mail No. ____________________
Return Receipt Requested
October 1, 2005
Dr. John Doe
Acme Insurance Company
1234 Elm Street
Anytown, ST 00000
Re: Appeal for denied X medication for John Smith's heart condition
I.D. Number: 1234-5678
Dear Dr. Doe:
On August 17, 2003, Dr. Nancy Martin, a cardiologist in Anytown, diagnosed me with advanced heart disease and prescribed X medication as my primary treatment. Your insurance company denied my claim for medical coverage of this treatment on September 20th. With this letter, I am formally appealing the denial of X medication coverage on the grounds that this is a medically necessary procedure, without which my condition will only deteriorate further and seriously impact my health.
Let me give you a bit of background about who I am. I am a 57 year old white male who has worked for XYZ Industries as a senior accountant for the past twenty years. I began having chest pains and feeling very tired all of the time around July, 2003 and eventually, I became alarmed when the condition did not disappear and I grew increasingly tired and experienced more frequent chest pains. I went to my physician for a general checkup in July, 2003 and was referred to Dr. Martin, who diagnosed me with advanced heart disease.
Although I am an accountant and my job does not require much physical labor, I struggle daily with my accounting duties and feel certain that I am going to be forced to retire from my position if I do not receive the medication my doctor has prescribed for me. I have taken other measures to improve my health, such as going on a special diet and watching what I eat; however, my cardiologist has informed me that my condition has not improved at all as there is a genetic component to my illness that cannot be resolved with diet and exercise.
The X medication that you have denied was prescribed by my doctor and is considered by those who set medical guidelines to be a medically necessary treatment for one with my condition. In addition, this medication is one covered by you. I have enclosed a (1) report from my physician; (2) a copy of the standard guidelines for heart disease treatment; and (3) a copy of that portion of the benefits handbook provided by your company indicating this treatment is a covered benefit.
I am requesting that your decision by reversed and that the X medication by covered by you as soon as possible as I need to continue on this medication in order to remain gainfully employed and healthy. Thank you for your time and consideration, and I hope to hear from you in a timely fashion, as I would like to resolve this matter as quickly as possible.
Sincerely,
John Smith
[if your contact information isn't included in the letterhead at the top, include it here]
Enclosures:
(1) Medical Report and written opinion from Dr. Nancy Martin
(2) American Heart Association's medical guidelines for treatment of advanced heart disease
(3) Page 47, paragraph (b)(iii) of Acme Insurance's Handbook indicating that prescribed treatment is a covered benefit
(4) A copy of my complete medical records
