Insurance claim rejected? Well, it’s not a complete dead end, but you will need to file an insurance appeal.
Since the average insurer isn’t the most empathetic, you’d better have Martin-Luther-King-Levels of persuasiveness. Insurers are experts at poking holes in arguments, especially written ones.
So before your fire off that appeal letter or e-mail, check out the pointers in this article.
1. Find out why your insurance claim was rejected
First things first, before you go ahead and write that appeal letter, you need to know why the claim was rejected. If it is because the illness is not covered or that you have exceeded the coverage limits, you might not have a case. Don’t waste your time on an appeal. Learn from your lesson and get better insurance next time.
But if it is something you can fix by asking for a doctor’s letter, rectifying a billing error, or supplying other forms of evidence, you’d definitely want to put your letter-writing skills to task right away.
2. Get straight to the point
The opening paragraph should not be a rant on how enraged you are, why you’re disappointed, etc. There’s room for that, but it’s at the closing of the appeal letter.
Like any other complaint that you are making, you should give exact details such as policy number, name, contact numbers and the reason for your appeal.
The opening needs to be instantly relevant, because that’s when you have the insurer’s full attention.
And you want to include the following straight away:
- A short sentence about your claim and why it was rejected
- A summary (maybe like this set of bullet points) on why you are appealing
- What you expect the insurance company to do (e.g. full pay out? Partial? Send you an apology? etc.)
Ideally, you all that in a single opening paragraph, in 100 words or less. Avoid verbose words as it will cause readers (your insurer) to start “skimming” and they might miss details.
3. Get supporting documents for the insurance appeal
Don’t just write “according to my doctor / dentist / mechanic…” If you have a supporting statement from a professional, get it directly from them and include it in your insurance appeal.
Most doctors only charge a small fee to write a supporting statement, and some family doctors don’t charge at all. If possible, get a referral (and subsequently a letter) from a specialist. This is typically used for late injury claims. Say, for example, you got whiplash from an accident. But you didn’t notice till after you made your claim. You’d then require a doctor’s letter, stating your current condition is due to the same accident.
If you’re dealing with car insurance, ask the mechanics for detailed receipts or invoices. You might also visit more than one approved mechanic, and request quotations from them. This is especially handy when disputing repair prices.
4. Mention if family members also have policies
If your other family members have policies from the same insurer, you should mention it. Don’t devote a whole paragraph to it, just slip it in a sentence, like this:
- …which especially concerns me, as my wife also has a policy from you
- …and is also a concern to my immediate family, all of whom buy policies from you
- As all of my family (wife and three children) have policies under you…
Most insurers dislike the prospect of losing several policies (your whole family) at once. But whatever you do, never phrase this as a direct threat. Insurers are human too, and dig in their heels.
5. Name names, if you have spoken to someone
Before you were told to file an appeal, you probably had phone conversations with your insurer. While you were doing that, you may have gotten some employee names.
Be sure to mention those names when writing your appeal. First, this prevents the notorious “ping pong” effect. If you write that “I spoke to Melanie and was told file an appeal”, that is likely to be more effective.
6. Mention the follow-up
Prompt the insurer for a follow-up. The easiest way to do this is to write: “I hope I can get a response by next week. Otherwise, I will follow up within the next X days.” Make it apparent that you will become
troublesome persistent if they don’t give you a response. This will warrant some much needed attention, as you’re competing with a towering pile of appeals.
And if the insurer doesn’t follow up, you now have a record of it. In the event of legal dispute, you can prove the insurer was reluctant to communicate with you “despite your best efforts”.
7. Explain how it saves them money
This trick usually works for medical insurance appeals.
They don’t want to pay for your inhaler? Fine, they can pay your hospital bills when you next have an asthma attack. Don’t want to pay for dental surgery? Sure, but it could mean a root canal they’re paying for one day. The idea is that, by not helping you get the equipment or procedure you need, the insurer could end up paying even more in the long run.
Simply explain how covering the cost of your procedure can save your insurer money. As with point 3, don’t make it a direct threat, but concisely remark that it’s “mutually beneficial” for them to cover it, and have your doctor offer a cost comparison.
If all else fails, contact FIDReC (Financial Industry Disputes Resolution Centre Ltd), an independent organisation for resolving disputes between financial institutions and consumers.
Still worried about getting good insurance?
Get a good insurer, and you won’t have to do any of this. Do some research when getting insurance; don’t just pick from the companies that call you first.
Have you ever written an insurance appeal? Comment and let us know how it went!
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