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
RE: APPEAL OF DENIAL OF BENEFITS
Contract Name: _______________
Member Name: ________________
Contract Number: ______________
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 Principal’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 – 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,