Insurers must make difficult decisions about the coverage of treatments. There is often a fine line between a medically necessary treatment and an optional treatment; for example, if a patient has a benign cyst on his forehead that is painful, but is not harmful to his overall health, the insurer must decide whether to cover that treatment. If a particular claim is denied, patients have the option of appealing the insurer's decision. The appeals process can be complicated, but one element of the appeal is a letter from the patient asking the insurer to reconsider the decision.
Begin the letter as you would any other business letter. If your letter is not written on letterhead, list your address at the top of the letter one line above the date. Type the date next, and two spaces below that, the insurer's name and address. If you have a case representative at the insurance company, type that person's name above the company name.
Type a subject line that briefly states the letter is an appeal of the the denial of coverage for a specific procedure. Also include your name, policy number and group number in the subject line.
Type "Dear (Name of representative)" or "Dear Sir or Madam" followed by a colon. If possible, call the insurer to attempt to get the name of your representative, as a letter addressed to a specific person is more likely to be addressed quickly than a letter to a general audience.
Start the first paragraph by stating that this is an appeal letter for (type your name) with regard to (state the procedure). Give the date of the denial letter, and state why the procedure was denied by the insurance company. Ask the company to reconsider its decision.
Discuss the need for the procedure in the second paragraph. Use the physician's decision as support, and enclose a letter from your physician that states the medical reasons as to why the procedure is required or necessary. Explain what might happen as a result of you not undergoing the procedure.
Inform the insurer that you are presenting additional evidence, such as the medical report and the letter from the physician, for their consideration. Keep your tone matter of fact and calm, but firm. Detail the expertise of the physician and the medical facility as support.
Formally ask the insurer to reconsider the decision and to cover the procedure, based on the supporting documentation from your physician. Give your contact information and the physician's contact information.
Type "Sincerely," and skip three lines. Type your name. Print the letter and sign above your name.
Make two copies of the letter. Retain one for your records and forward the other one to your physician.
Mail the letter with the supporting documents to the insurer. If the procedure is scheduled to happen soon, mail the documents via Priority Mail from the United States Postal Service or a similar service.
Call the insurer after one week and ask if they have received the information.
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