Appeal Letter to Medical Insurance Company

Rejected Insurance Claim

An appeal letter to medical insurance company is necessary if your claim has been denied. Sometimes the appeals are handled by the hospital or doctor's staff, but other times it is up to the patient to pursue this matter.

Writing an Appeal Letter

In starting the appeal process, there are a few things you will need. Along with the appeal letter, your doctor or other medical specialist will need to write a letter about your case. You either need a copy of your medical records or all the information relevant to your claim. You might also do some research for articles that pertain to the specifics of your treatment. The tone of the letter should be pleasant as you are simply stating the facts and requesting reconsideration.

What to Include

When writing an appeal letter to medical insurance company, make sure you include all the identifying information from your policy including:

  • The policy and group number
  • The number of your claim
  • Any other vital information

Your letter also needs to contain the company's reason for denying your claim and an overview of the ailment and treatment received. Make sure that all the information is accurate, because there may have been human error at the root of the denial of your claim.

State why you think that the claim should have been allowed. For instance, there are allowances made for going out of network for certain medically necessary treatments. State clearly what you want the insurance company to do. This is usually a request for them to reevaluate and approve the claim as soon as possible.

Submission Tip

Make sure the address is correct. The appeals department may have a different address than the address for submitting claims. You should mail the letter by certified mail and request a return receipt; this is the only way to know it arrived.

Sample Medical Insurance Appeal Letters

Sample Letter 1

Following is a sample of an appeal letter to medical insurance company in the case of a denial based on medical necessity. In the header put your name and address, the date, and the Claims Review Department's address. Continue with:Re: John Doe Policy #1111111

Claim #2222222

Dear Claims Review Department (or individual's name if you know it):

You denied John Doe's claim because it was not medically necessary. His treatment was given by Dr Smith on May 13, 2050. I feel your decision is in error and would like to appeal the denial.

John Doe was diagnosed with Some Disease on April 1st, and Dr. Smith felt that he would benefit greatly from the New Procedure. I have enclosed a letter from Dr. Smith detailing John Doe's medical condition and treatment.

I appreciate your review of this matter. Feel free to contact me at 555-555-5555 if more information is needed.

Thank you for your time and attention to my appeal.

Sincerely,

Jane Doe

Sample Letter 2

Following is another example of an appeal letter to an insurance company that has denied a claim. The reason for the denial in this case was the out of network treatment.Dear Mr. Fairman, Please accept this letter as my appeal to Healthy Insurance Company's denial of my claim for special radiation treatment. I understand that you denied payment for this treatment because it was administered by an out of network provider.

My primary care physician, Dr Wright, believed that this treatment was the best option for me and no providers in the network offer it. I was treated at New Age Medical Clinic by Dr. Betters.

I have enclosed a letter from Dr. Wright explaining his reasons for recommending this new treatment and a letter from Dr. Betters giving the details of the treatment and his qualifications. For your information, I have also included two articles that explain this procedure.

I ask you to reevaluate my claim and allow this out of network treatment. Do not hesitate to contact me at 666-666-6666 and I look forward to hearing from you soon.

Sincerely,

David Jones

Sending the Letter

Make sure you are polite and professional in the letter. Be detailed and support your case. Send the letter registered or certified mail so you can be sure the insurance company receives it and will work on your case.

Appeal Letter to Medical Insurance Company