It is an open secret that medical expenses can get very expensive that it becomes a reason why many people join health insurance company. However, the worst scenario happens when the insurance company denied the patient’s claim to pay specific amount of money for the treatment. The patient has the right to write a denied claim appeal letter and find a way so that the health insurance pays for it. However, there are valid reasons behind the denial of the patient’s claim so make sure you check the information below as well as the sample of how to write an impactful appeal to the insurance denied claim.
What is Denied Claim Appeal Letter?
When a health insurance company denies claims, it means they do not agree to pay specific amount of money for the patient’s treatment. A patient has to the difference between the denied claims with the rejected claims, in which the patients cannot appeal the decision. The patient has to resubmit the claim and wait for the company to process the claim. Usually, it happens because of the wrong information given by the patient while making the claim. So, make sure to know the situation before sending the denied claim appeal letter to the insurance company.
Three Reasons of Denied Claims
There are a number of reasons why your health insurance company denies the claim. The first reason is because the treatment or medication is not a part of insurance plan. Another reason is because the necessity of the medication received by the patient, that is considered not urgent by the insurance company. The last reason is the over limit from the plan that patients have. Each company insurance usually provides the coverage limit for the payment in each plan, so if it is over the top usually the company decides not to pay.
Sample of Denied Claim Appeal Letter
If the above reasons do not apply in your situation and the insurance company denies the claims, you have the right of sending a denied claim appeal letter to the insurance company. Here is a sample of appeal letter sent by a patient who received an urgent surgery because of the worsening condition following the accident before.
Dear Mr. Johannes,
Following the denial claims released by Family Health Insurance Company on 28 July 2019, I am, Georgia Willy, writing the appeal letter for the coverage of abdominal surgery that I received on 1 July, 2019. Based on the letter, the main reason for the insurance company to deny the payment is because of unnecessary perform of surgery.
I had a bad abdominal pain and I was found unconscious by my daughter at home. The doctor said had it been longer by a minute, I would not make it. The doctor said the pain came from the effect of accident last month and he took a quick action by performing the abdominal surgery to see the root of the problem. It was found out that there is internal bleeding that may damage my organ and the surgery is the best decision to stop the bleeding. I have attached the detailed explanation from Dr. Rigan, who performed my surgery. I am asking you to reconsider the decision as it was the urgent surgery action to save my life.
The denied claim appealletter above shows the exact situation of the patient without exaggerating the factual information. We hope this letter can be as a reference for you to write the appeal letter. Good luck!