Childhood Cancer

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Your Child in the Hospital

Appealing a denial

If any of your insurance claims are denied, you have the right to appeal the decision and have it reviewed by a third party. First, make sure that the service is covered by your insurance policy. If it is, following are suggested steps to appeal the denial:

• Read your policy or the back of the explanation of benefits to learn what your insurance company’s appeals procedures are. Sometimes there is a time limit, so you need to file the written appeal before your time runs out.

• No matter what they tell you on the phone, appeals must be filed in writing.

• Write a clear letter explaining why the insurance company should reconsider its decision, and attach a copy of the denial letter from the insurance company. Keep original documents in your files. Insurance companies have to respond in writing to your written appeal to explain why they denied your claim (this is called an “internal review”).

• If your claim is denied a second time, request an “external review.” In this process, your appeal will go to an independent third party for review.

• If you have problems with the appeal process, you can contact your elected representative to the U.S. Congress. All Senators and members of the House of Representatives have staff members who help constituents with problems.

• You can also contact your state insurance commission with concerns and complaints.

When I ran into insurance company problems, I wrote a letter to the insurance company detailing the facts, the decisions the insurance company made, and a logical explanation about why the procedure needed to happen. I also noted on the letter that a copy was going to our state insurance commissioner, and I sent both letters by certified mail. Within two days, the insurance company all of a sudden decided to cover the procedure. I later found out that the insurance commissioner’s office started an investigation against the company. Letters help, especially when sent by certified mail.

You may not feel comfortable being so persistent, but sometimes it is necessary to ensure you get the coverage you and your child are legally entitled to receive.

When I finally got a case manager assigned for my child within our insurance company, I fretted to her one day that every single claim was initially rejected. She replied that the agents were trained to reject all claims the first two times they were submitted as a cost-saving strategy. She said, “Very few subscribers are tenacious enough to come back three times, so we save millions of dollars each year just because they give up.”

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