Medical Debt:  How to File an Appeal if Your Medical Insurance Claim is Rejected

Since an insurance company's main goal is to maximize profits and minimize expenses as much as possible, they routinely reject or underpay medical claims submitted to them.  Most people just give up rather than fight the insurance company; however, you might be able to get the decision reversed by following just a few simple steps.

First of all, the initial rejection of your claim might not be personal.  The insurance company might have sent you a form letter sent to all claimants who want reimbursement for a particular procedure or drug that they have pre-determined will be rejected.  When this happens, you need to get confirmation from your doctor that the procedure or drug you need is medically necessary and critical to your health, rather than just beneficial.  Ask your doctor to write a letter of medical necessity about the treatment or drug in question for you to submit to the insurance company.

You can also do some research over the Internet to find out if the drug or procedure your doctor wants you to have follows basic guidelines endorsed by major medical organizations such as the American Heart Association.  For example, at a medical website, one could type "standard guidelines" in the search box to find out what guidelines have been set for doctors treating patients with your particular medical condition.

If you find out from your doctor or the internet that the procedure or drug is medically necessary, file a former appeal with the insurance company by sending them a letter wherein you use the word "appeal".  (Sample letter below) Send any supporting documentation along with the letter and send all of it certified mail, keeping a copy of the letter and your original documentation.  The insurance company is required by law to process your appeal in a timely manner.

If your insurance is provided through your employer, send a copy of your appeal to the person in charge of Human Resources or the Health Benefits Administrator.  If they are looking out for their employees as they should be, they will put added pressure on the insurance company to reverse their original decision. 

Don't be afraid to contact the reviewers handling your appeal.  A reviewer ight be a nurse or medical director or other person who works in the healthcare industry.

What happens next?  Statistically, if your appeal is heard by a panel of outside reviewers, there is slightly more than a 50% chance the decision will be reversed and the drug or procedure in question will be covered.

Sample Letter:  Appealing a Medical Insurance Claim That Was Rejected


Certified Mail No. ____________________
Return Receipt Requested


Date


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, 2010, 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 20, 2010.  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, 2010 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, 2010 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
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