writing an appeal letter to insurance

[admin]

Hi,

My name is Erin and I am trying to help a friend of mine with a brachial plexus injury write an appeal letter to her insurance company. She needs to go out of state to have a special surgery. Of course, insurance is denying her coverage. Do you know of anyone that has dealt with this sort of thing and might be willing to share some letter-writing tips?

Thank you so much.

Erin G.

[shelbel1950@aol.com]

Hi Erin, I had to write an appeal letter for my 23 yr old daughter's tbpi. We were fairly successful am still waiting for more responses. You'll need to be detailed with the appeals board and detailed about whomever out-of-state is going to do surgery,etc. The appeals bd needs to know why they are so special and why the dr around the corner from you isn't. I also told them very politely that they needed to tie their tbpi arm around their back while meeting for this decision and to carry on like that for a 24 hr period, doing literally everything that a person does in that 24hr period (that the tbpi's do also) to know what it's like to have this type of injury and at the same time be denied for any assistance from their ins co to get a chance at making it better for them. Those ideas I put in BOLD lettering...the whole paragraph and also the reminder of their insurance denying them anything at a chance to receive help and finished off with the old "how does that make you feel?" statement. Don't get me wrong, I wasn't rude about it but very aggressive. Alot of those boards are compromised of regular people like you and me and are not familiar with this injury and definitely need to be educated about it. This is your chance or the family's chance. We need people with determination to help with that. At the same time, keep the name and so forth of the person at the ins co you're working with, so that you can follow up with him/her after a short period of time. YOu also need to talk with the dr/s you're wprking with to let them know what you're doing because so many of them are so very patient and helpful while you're going through this. Make sure you have researched this out-of-state dr so you can back yourself up in the letter and on the phone. Good Luck! Any questions, feel free to e mail back.

Shelley

[Peyton and Teresa]

I would go through your primary care physician (pediatrician) and ask them to set you up with a case manager with your insurance. We have one for our daughter and they "Can" work around alot of things. Be persistant!!!

[admin]

Erin,

Get letters from whoever you can, primary doctors, old pediatrician, therapists, bpi specialists, orthopaedic doctors, whoever. Also, try to find any information, literature or possible data that supports the need for surgery, the possible benefits/outcomes, etc. And keep appealing to higher levels. Also, if you know any attorneys, get them to send in the information attached to their stationary. I have heard wonders happening when lawyers are involved.

Lastly, I was very touched by your post. You sure must be a special person and an incredible friend! Good luck helping your lucky friend and keep us posted.

[BrookesMom]

Hi! I know this is very frustrating for you. I went through the same thing with my insurance company. I am a lawyer so I took my approach from a legal point of view.

The first thing you need to do is find out exactly why they are denying your claim. The claim is usually denied on one of three basis:
1. The insurance company does not think the surgery is medically necessary and/or
2. They say there is someone in-plan that is qualified to perform the surgery and/or
3. The insurance does not cover this type of surgery.

In regard to no. 1 you need your doctor to state why the surgery is necessary - i.e. your child will be permanently disabled without the surgery, the surgery is proven to help children with BPI etc. The insurance company may have had an in-house medical panel review your case. This is not acceptable. Usually these medical panels are not doctors (nurses, etc.) and have no clue about BPI. You need to let the insurance company know that you expect better service. If they are going to deny your claim based on necessity they have to speak with medical personnel who are knowledgeable about brachial plexus. They owe you a duty of good faith as your insurance company. (See good faith explained belo).
In regard to no. 2 - BP surgery is a very specialized area and only doctors with expertise can actually help your child. A regular pediatric orthopedic surgeon will not do. In order to prove this you should go on the UBPN web site and or the internet and pull all research materials stating that it is a specialized area. Your doctor and OT/PT should also write a letter to this affect.
In regard to no. 3 - You need to look at your insurance policy and see what conditions are covered.

You need to stress to your insurance company that they have a duty of good faith to you and you believe that they are currently in breach of contract (your health insurance plan is a legally binding contract)and acting in bad faith by denying this claim. (This is legal terminology where the law in every state will allow punitive damages to be collected against an insurance company if they breach the contract and act in bad faith in processing a claim).

Also, in your appeal letter you should ask for a copy of your child's entire claim file in case you need to pursue other legal remedies.

"CC" your appeal letter to the insurance commissioner in your state along with a completed Formal Complaint form asking them for help with your claim. Make sure you followup with the insurance commissioner as they can be very pursuasive with your insurance company. Also, make sure the "CC:to insurance commissioner" is at the bottom of your appeal letter so the insurance company knows you are making a formal complaint. This may motivate them to cover your claim.

Lastly use any information supplied by the insurance company against them. For instance, if some adjuster told you at some point the claim would be covered make sure you put that in your letter with the name of that person. If they covered preliminary tests for BPI than this shows that BPI is a covered medical condition under their policy.

Please feel free to e-mail me directly if you have any questions.

Cheryl Wingate,
Mom to Brooke Mollie - ROBPI