Sometimes health insurance companies refuse to pay for a service for any number of reasons. It may be that the service is not covered under the patient’s policy, the coverage may have been terminated prior to treatment or the service may have required pre-authorization that was not done. Patients who believe their claim was wrongly denied can write a health insurance appeal letter.
Format and Content
When a patient receives an insurance claim denial, the patient can object to the decision but should submit it in writing in a health insurance appeal letter format. The letter should include the patient’s group, policy and claim numbers. It should also include the procedure that was denied and the date of the denial.
This health insurance appeal letter sample is from a patient who went to the emergency room with chest and abdominal pain and ended up having emergency gall bladder surgery due to multiple gallstones. The insurance company denied the patient’s claim stating that the surgery was not pre-authorized and the condition possibly could have been treated with medication instead of surgery.
98 Treetop Lane
El Paso, Texas 11111
XYZ Insurance Group 101
Mr. Roger R. Grant
XYZ Insurance Company
P.O. Box 9876
Chicago, IL 55555
October 1, 2013
Re: Health Insurance Appeal
Dear Mr. Grant,
Thank you for speaking with me by phone this afternoon regarding my claim number 333 for my September 10, 2013 emergency gall bladder surgery that was denied by XYZ Insurance Company as non-emergent and for no pre-authorization. I have attached all documentation you requested including the ER notes, the physician notes and the result of my ultrasound and blood work. In addition, I have attached a letter from Dr. Charles Anderson who saw me in the emergency room and ordered the surgery.
When I was at home I was suddenly struck with excruciating pain in the lower chest and upper abdomen. My wife called an ambulance and I was rushed to ABC Regional Medical Center. After a quick examination to determine that I was not having a heart attack, some tests were performed. An ultrasound showed numerous large gallstones in my gall bladder. Because of the severity of my pain and the extreme size of the gallstones the doctor felt it was in the best interest of my health condition that he perform emergency surgery right away and remove my gall bladder.
XYZ Insurance Company denied my claim when it was submitted stating that the condition was not a true emergency and that it should have been submitted first for pre-authorization; however I believe that the supporting documentation I have attached will prove that this was a true emergency and that the surgery was the best course of action under the circumstances. I ask that you review the attached documents and reconsider my claim. Dr. Anderson has stated that he is available for a telephone interview if necessary. Thank you in advance for your time and consideration.
Samuel C. Gray