How to Appeal Your Health Insurance

1.

Ask the customer service executive of the health insurance company about the procedure to make a formal appeal. You can also find the information on the company's website.

2.

Draft and send your formal appeal letter, or create and submit it online. Write in-depth about the disease that the person was hospitalized for, the doctor's recommendation and treatment, medical fees and reasons for filing the claim. Furnish medical records that add weight to your appeal.

3.

Draft and mail a letter to the head of the insurance company or any responsible high-authority employee if you feel that your case hasn't been given its merit. You can get the email address from the company's website where you can send an email to report grievances regarding your appeal.

4.

Escalate the appeal to your state's insurance commissioner if you're not getting a response. Send a copy to the head or the respective authority employee of the insurance company. Attach previous correspondences to let them know how strongly you've pursued this matter.

5.

Notify the local Better Business Bureau if you notice any discrepancies, loopholes or callousness in the way the company has handled your insurance claim. Maintain a record of all the correspondences; make a note of the dates and the people whom you talked to, so that you have a record for reference.

Tips and Warnings

  • The health insurance company has its reasons for rejecting your claim, and, usually, the company writes just a line, which may look like jargon, citing the reason for not honoring your claim. Ask the customer care division for more information on the issue. Also, read your health insurance offer document carefully for the coverage amounts, exclusions, disclaimers, information about its network hospitals, cashless schemes, hospitalizations, surgery-related conditions, etc.
  • Continue to follow-up with your health insurance company, because, once the company rejects a claim, it moves on. You have to stop the company, and let it know about your case.
  • People file an appeal with their health insurance provider when the company doesn't honor their claim. Usually, according to the given set of clauses and conditions that are laid down, it's the responsibility of the health insurance company to honor the claims sent by the insured or the medical service provider. Nowadays, the hospital sends the claims directly to third-party providers of the insurance company or the health insurance company itself to process the claim. When the insurance company rejects a claim, the individual has the right to appeal to the company.