How to Appeal a Denied Health Insurance Claim

By Larry A. Tawwater on March 15, 2018

You have current, valid medical insurance. So why was your claim denied? This is a frustrating scenario that many of our clients face. According to the United States Department of Labor, one out of seven claims is initially denied. Our health insurance lawyers at the Tawwater Law Firm in Oklahoma City, OK, are here to defend your rights should you receive a denied health insurance claim. Read on to learn why this happens, and what you can do about it.

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Why Appealing a Denied Claim is Important

The crucial thing to remember is that insurance companies have one primary goal: to make money. However, it is also important to understand that many times, a claim is denied simply because the insurance representative did not understand the full details of the case. For example, a claim could be initially denied because the treatment sounds more like a cosmetic procedure. However, in certain cases, cosmetic procedures can be performed for medical reasons. Things like this happen all the time in the world of medical insurance. Therefore, it is important to appeal any denied claims to obtain the coverage you deserve. Doing so achieves three significant things:

  • You can “exhaust” all of the appeals required by law before filing a lawsuit against the insurance company.
  • Your appeal will be included in your file at the insurance company, therefore showing support for your actions.
  • The insurance company will have no choice but to comb over your treatment case again and look for things they may have missed the first time.

How to Appeal a Denied Claim

There are a few different ways to appeal a claim. First, you can simply send a written letter. Make sure to send it via certified mail so you can confirm that it was received by the company. Secondly, you can call the company and verbally appeal the denial. It should be noted that this is not the best option, as there are no written records of the call taking place. Thirdly, you can request expedited service if you have time-sensitive medical reasons for doing so. This can generally be accomplished through a “peer to peer” call between the insurance company and a medical provider.

When to Appeal a Denied Claim

Appealing a denied claim is a time-sensitive action. Most insurance companies state that you must appeal the denial within 180 days of receiving the EOB. However, every insurance company is different, so it is important to check the details of your specific policy.

What to Include in the Appeal Letter

You will want to address the insurance company in a brief and succinct way. For example, give a point-by-point recap of your medical history, diagnosis, and treatment plan. Highlight the points on the denied claim where the insurance representative got it wrong, and directly quote the denial when appropriate. Lastly, close your letter with a specific request to overturn the denial and pay the benefits immediately. Documentation is key. Be sure to enclose any radiographs, test results, diagnostic photographs, or any other pertinent information.

Contact Our Health Insurance Lawyers Today

If you have tried to appeal a denied health insurance claim to no avail, contact the Tawwater Law Firm today. Our experienced attorneys can represent you and help you fight for what is rightfully yours. Contact us online or give us a call at (405) 607-1400.

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