How to Appeal for Denied Health Coverage –

approved or denied

Health insurance is one of the policies that are necessary to have because at one point, all of us will require some sort of medical treatment and service. If you are uninsured when a health condition occur, that could mean a considerable amount that you have to pay out-of-pocket. This can vastly impact your budget and current finances.

Basically, a health insurance policy works by shouldering the medical expenses and treatments that you have incurred. Surely, it seems like a great strategy in order to thwart the effects of medical expenses on your finances. But, what if your insurer refuses to pay off your claims and states that your condition is excluded from your policy? If you find yourself in this scenario, don’t fret as you have every right in the world to appeal. Here’s how.

1. Do it right away.

If you get denied and you want to place an appeal, it is best to do this right away. Most insurers have a set window of 30-40 days when it comes to this kind of concern.

2.  Ask for a letter of denial.

Have a letter of denial sent to you. This way you will have a written explanation on why you have been denied of your claims. Once you have this document, you can examine, word per word, the grounds by which they have based their decision to refuse you of your benefits.

3.  Refer to your policy.

Once you have the letter of denial in hand, the next thing you need to do is to check your policy. See if what the letter said is parallel to what your plan says about its coverage and exclusions. It’s very typical for insurers to commit mistakes in this area. In fact, an audit done by the Patient Advocate Foundation in 2005 show that 96% of denials were actually included in the policy.

4. Write a letter of appeal.

Once you have clarified that your claim is indeed covered by your plan, you have to come up with a letter of appeal.

Being denied of your claims can be stressful and emotional, but as you write your letter of appeal, it is advised that you keep it simple, clear and objective. As much as you can, keep your emotions out of it. Including your feelings may look like you’re pleading or begging for what is rightfully yours in the first place.

To make your letter more effective and strong, it is best to match it with the language of your policy. This way you can place concrete arguments and points. If you need help in this area, you may seek the help of your doctor as he can provide a thorough explanation of your condition.

5. Keep track of everything.

As you go through the process of appealing, it’s crucial that you keep a record of everything. Keep a log of all the calls, name of the people you have talked to, dates, documents, receipts and any piece of information that is related to your appeal. This way, you can easily back track on important details regarding your situation. More so, this record can be your proof should there be any discrepancy along the way.

6. Be persistent.

Don’t take no for an answer, especially if you know that you are entitled for your coverage and benefits. Never back down in the middle of this process. If talking to a company’s representative seems like you’re not getting across, don’t hesitate to raise this issue to the higher-ups. This may increase your chances. Doing so will also show that you are serious about your appeal.


The Advantage of the Affordable Care Act

Before, the process of making an appeal was based on which state you live in, the kind of health plan you hold and whether you bought it individually or acquired it through your employer. Some states didn’t constitute any sort of appeal rights, while others allow you to petition the denial with the help of a third-party expert.

However, when the Affordable Care Act took effect in 2010, the nature of appealing for denied claims changed. Now, when you petition a denial, it is mandatory that your health plan review your case. If your insurer still refuses to pay for claim, then you can seek an independent reviewer to take a look at your appeal. This is applicable to plans purchased after March 23, 2010. If you acquired your plan prior to that date, you can clarify with your state insurance department or employer if the same mandate can be applied to you.

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