What is the best way to fight an insurance denial?

I had to have a procedure done last week. If I hadn't had it I would have ended up having a larger more complicated surgery that would have possibly left me with the inability to bear children. My insurance company denied payment on the procedure because they said it wasn't necessary because I wasn't going to die if I didn't have it. I have three doctors who think otherwise. While I wouldn't have died, there would have been serious problems if I hadn't had it. What's the best way to convince the insurance company to pay for the surgery? They said I have 60 days to appeal.

To start with I am happy that everything has worked out. Now insurance is nothing more than a contract. So we use the acronym RTFC...read the freaking contract. Insurance contracts are great because the law requires that they provide you explicit language that if you follow it they must pay. So start with your policy. Now where you ask. Look first to what is covered. Now you may have to read into it. But generally contracts have provisions for providing coverage for everything except that which is excluded. Then even the excluded stuff is covered if you show necessity. Showing necessity is where you need the help of your doctors and the a declaration from them that states why it should be covered.

So step one. Write your appeal. Be Professional. Have evidence supporting that your surgery was a necessity and beneficial to you and cost effective to the insurance carrier and that it was not experimental but scientifically proven as most effective.

You appeal should go like this:

The Principal Via Facsimile
Post Office Box 57700 801 268-6070
Salt Lake City, UT 84157-0700

Attention: )________________________

RE: APPEAL OF DENIAL OF BENEFITS

Contract Name: _______________
Member Name: ________________
Contract Number: ______________
Dear ___________:

Thank you for taking my telephone call this afternoon concerning the Principals denial of policy benefits.. This letter shall serve as an appeal to the Principalâ€™s decision denying policy benefits to __________, your insured.

I have been treated by ____________. Attached is a declaration by Dr. _________ demonstrating my necessity for this treatment, its efficacy and ______________________ (insert exact policy language of why they should pay â€“ put it in verbatim)

Then tell of the procedure. Attach literature of it. That it is a generally accepted procedure in the community.

Based upon the plethora of literature and the number of treatments given in many different practices across the state, the literature from Stanford to Harvard are all overwhelmingly supportive. This treatment works, it is cost effective and adds great benefit to the individuals who use it.

It has been __months since ___________ and I am starting to really feel the positive results. Bla blab la

Please reconsider your position on your denial of policy benefits and pay the doctors claim of __________

Thank you for your courtesy and cooperation in this regard.

Very truly yours,

First, you should make the formal appeal process. Your doctor may have to provide details about the medical necessity of your procedure.

If they contitnue to deny the claim, contact your state's insurance regulator to complain about an unfair claim denial. Every state has a process you go through to force an insurer to pay a claim that is deemed proper.

It may take a bit of paperwork, but you will likely prevail.

A suggested first step....have your doctor write your insurer to show how much more expensive it would have been later for your insurer had you not had the procedure done right away.

One caveat......you need to dig out your policy and read it to see if there are any exclusions or other special circumstances about your specific procedure.

Collect letters from the three doctors stating the reason for the surgery. Did this procedure have to be precertified? If so, was it done? If not, is it a covered benefit under your plan? Keep copies of all the bills and letters involved with the procedure. Write an appeal letter and submit a copy of the doctors letters with it. The insurance company should then request medical records. I hope it turns out in your favor.

James D had a great answer! I have trouble believing that the doctors office didn't get precertification. Doctors do love to get paid! I have a great luck fighting insurance companies with just phone calls. Sometimes something doesn't get coded right. When that fails I send letters, and one time a photograph of the removable cast that the insurance company seemed to think was an arch support.

Also, 60 days seems like a short appeal time. READ the contract and the letter of denial closely and act quickly. By the way, the insurance company will stall as long as they can.

did you get a pre-approval before? if not then you will have to probably have this group of doctors file their reports to the state insurance board for their examination to force the insurance company to pay their part!

You need to consult a lawyer who specializes in medical insurance claims. You should have no trouble locating one. They are generally referred to as "Ambulance Chasers". They will start by telling you if you have a case. (I think you have a case but I'm a Systems Analyst, not a lawyer.)

The lawyer will gather testimonies from the three doctors you mentioned, and anyone else involved. He will build a case, and probably win. The chances are that you won't even have to pay the lawyer; the insurance company will.

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