I was doing my New Year's clean-up of my files and found I had saved the following example of a letter to send to your health insurance company if you have a claim that has been denied and you want to appeal. This appeared in Money Magazine in the July 1997 issue. Description of info to be supplied by you appears in brackets. Although this may not fit every situtation, I think it provides a good template.
Mindy
Director of Appeals
Appeals Committee
[Name and address of health plan]
[today's date]
Dear Sir or Madam:
Enclosed please find a copy of my medical report, prepared by [name of doctor] on [date], and a copy of the explanation of benefits form you sent to me.
According to this form, the reason for denying my [medical treatment or claim for payment] is as follows:
- .
However, page ___ of my employer's Summary Plan Description states the following as a benefit: [note the benefit you were denied that your plan says you are entited to receive].
I wish to appeal the denial of [treatment or payment], specifically the following: [note the treatment you are seeking or the payment owed for a treatment already received]. If you decide to deny my request, please list all of my medical records in your possession. Then, please indicate the portions of these medical records and the section of my plan description upon which you base your decision to deny my benefits. If you do not have all my medical records, please advise me and I'll have my doctor send them to you so you can reconsider my case. Finally, please provide me with the names of the persons who have made the decision to deny my [treatment or payment].
I look forward to hearing from you within 15 days.
Sincerely,
[your name]
