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How to Appeal for Denied Health Insurance Claims

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A health insurance policy is not a guarantee that you will get reimbursed for all your healthcare expenses, or that your hospitalization costs will all be shouldered (whether in part or entirely) by your insurer. Insurance might be marketed as a customer-centric product, but remember that behind these products are companies that must look out for their financial welfare. In all fairness, they also need to vet applications so that only qualified claims will be reimbursed.

What happens if your insurance claim is denied? You can file an appeal if you think the outcome has no basis and is unjust. If all else fails, our bad faith insurance attorney in Los Angeles is only one phone call away; but for now, let’s focus on your appeal.

What to Do If Your Insurance Claim Gets Denied

If your insurer denies your claim, they will send you an official letter stating the reason for the denial and possibly quote clauses in your policy that presumably justifies this decision. Don’t panic or be disheartened right away if you get such a response because you can still file for an appeal.

Here’s what you need to do:

  1. Review the appeal process for your insurance company. It differs for every company. Talk to your agent, and ask whom to address your appeal, what documentation you need to prepare, the deadlines for submitting an appeal, and so forth. The information may be available on their website, but it always helps to discuss it with someone knowledgeable about this process.
  2. Review your policy. Take note of the reason your insurer cited for the denial of your claims. Review the clauses that supposedly invalidates your claim. It’s not yet necessary to consult an attorney at this point, but it would be helpful if you can go through those clauses with people who know how to pick apart the legalese and show the key points of your contract.
  3. Prepare your letter of appeal and supporting documents. It must contain your personal information and insurance details. State the reason cited for your claim’s rejection. Explain why you think the resolution should be the opposite and that your policy covers your recent medical procedure or treatment (this is why it’s advantageous to have an attorney advise you on the details of your insurance policy and how to argue your position). If it supports your claim, include other documents like a letter of medical necessity by your doctor, results from first tests and second opinions. These documents should explain why the treatments you received were necessary for your health condition. Finally, produce and keep copies of your appeal documents in case you need references later.
  4. Submit your appeal documents. You must make sure that your insurer has officially received your appeal, so consider sending the documents via:
  • Fax (you can get a confirmation for a successful transmission)
  • Certified mail (you can request a Return Receipt)
  • Personal delivery (you can note the time, date, and name of the staff who received your appeal documents plus note your delivery at the receptionist’s log)

If your insurer still denies your claim, you may persist with yet another appeal, or you can escalate your response by filing a bad faith insurance claim.

Haffner Law can assist with your filing. We have years and years of experience in dealing with bad faith insurance cases, and we always work our hardest to help our clients get the compensation they deserve.

Contact us via our website and schedule an appointment.

(This is an attorney advertisement by Joshua Haffner)

 

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