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Reconsideration Letters - Appeal Your Health Insurance Claim Denial

Edward Neeman | Published: August 08, 2018

Writing reconsideration letter

There’s nothing more frustrating than having your health insurance company deny your claim, and understandably so. Think about it, you rarely ever seek medical attention, but still, pay a premium each month that stretches your paychecks thin. Now, the one time you need your health insurance company to step up, they send you a letter stating that you’re not covered for the services you received. What’s the point of having health coverage at all?

Dealing with health insurance companies is frustrating, there’s no denying that, but there is a way to fight back. There is a little-known appeal process that doesn’t take too much time or effort on your part but can end up saving you thousands on your medical bills. Introducing the reconsideration letter, a sliver of hope in the messed up world that is US healthcare.

Why Health Insurance Companies May Deny Your Claim

Before we jump into the process of appealing your denied claim, it’s important to have a good grasp on why a health insurance company would deny your claim in the first place. If you’re looking for a more comprehensive list, verywellhealth offers the top 10 reasons your claim may get denied.

Some of the most common reasons your medical claim may be denied are due to incorrect information. For example, something as simple as the wrong spelling of your name or date of birth can cause clerical errors which render your claim invalid. These issues, though frustrating, can usually be remedied fairly quickly and easily.

However, other times, your claim may be denied due to more serious reason. If you failed to pay your premiums, your coverage may have already been terminated, for example. In other scenarios, the service you received may not be covered by your policy, or you didn’t obtain a referral from your primary care physician before getting medical attention. In cases like these, it may be a bit more difficult to fight your claim denial. That being said, let’s jump into the next steps you can take to appeal the decision.

What Are Reconsideration Letters?

In this case, a reconsideration letter refers to an official and formal letter sent to your health insurance company in an effort to appeal the denial of your claim. Letters for reconsideration are not limited to health insurance, you have the ability to appeal any rejection from a company or official establishments such as a credit card company or university. Keep in mind that sending a reconsideration letter does not guarantee the decision will change in your favor.

Steps To Appealing Your Health Insurance Denial Claim

In order to maximize your chances of overturning your denied claim, it’s crucial you take a methodical approach. Before starting, visualize that this letter is going to be the only thing standing between you and thousands of dollars because chances are that will be the case. Use the following steps when writing your letter for reconsideration.

1. Gather All Necessary Information

Before getting started, the first step is making sure you have everything you need. The last thing you want to do is send a request and have it fall on deaf ears, or be incomplete. Here is what you’ll need:

  • Correct recipient/department and address.
  • Your health insurance policy number.
  • The claim in question.
  • Medical records such as transcripts, referrals, or receipts.
  • The claim rejection letter, including reasons your claim was not approved.
  • Evidence or facts that outline why your claim was incorrectly rejected (if available).
  • Arguments and reasons as to why your claim rejection should be overturned.

Gathering all the pertinent information, especially your thoughts, will help you write a clear and concise letter. Having everything in front of you will also allow you to make a better case for yourself, and find any discrepancies the health insurance company made.

2. Address And Explain Your Situation

You already have all the information you need in front of you, so make sure you are addressing the correct recipient or department. As mentioned before, the worst thing you can do for your case is spend all this time appealing your health insurer’s decision only to send it to someone who has no say in the matter.

After finding the correct recipient, make sure to thoroughly explain the purpose of your letter. Explain the current situation, the reasons were given as to why your claim was rejected, and finally, request that your claim denial is reconsidered.

3. Making Your Case

This is going to be the body of your letter. Making your case is the most important part of your letter, but it’s important to separate your emotions from the evidence. Stating that you’re upset about the decision is not as good of an approach as stating that a small clerical error is a reason your claim was rejected.

Present your evidence at this point. Since you already have the rejection letter in front of you, make sure to go through the reasons and accurately refute them. For example, if your policy outlines that you don’t need a referral from your primary care physician to see a specialist, but that was stated as the reason your claim was denied, make sure to provide the facts.

Make sure to be as detailed and specific as possible. If you have receipts and records of your own, make sure to include them. If you are missing anything, reach out to your medical provider as they typically keep detailed records of all patient interactions and appointments.

4. Your Conclusion And Contact Information

It’s time to wrap up your letter for reconsideration. While you don’t have to restate your case, a summary of your points and your request should be clearly stated just in case the recipient decides to scan your letter.

Also, make sure to include your contact information. First, adding your contact information and policy number will help expedite the process. Secondly, if there is any follow up or additional correspondence needed, providing your personal information will be useful.

Do Letters Of Reconsideration Actually Work?

Yes, writing a reconsideration letter can yield favorable results. Remember, health insurance companies are businesses with a bottom line to meet and will make decisions that benefit themselves. They are also run by people, just like you and me, and it’s possible to make mistakes.

If you can prove your case with reason, appealing a rejection letter can overturn their decision. Whether it is clerical errors or not, it’s worth fighting your claim denial. The worst thing that can happen is you get rejected, again.