How To Make a Successful Insurance Appeal

If you have a struggling learner, you may have some medical or therapy expenses that go along with the territory. If your struggling learner is borderline or does not have a specific condition or syndrome, getting an insurance company to pay for coverage can seem to be a daunting task. Here are some tips for making a successful appeal on an insurance claim:

  • Remember that insurance companies are for-profit businesses. Their goal is the same as any other for-profit business: to make money. The fewer claims they pay, the more money they get to keep.
  • An initial rejection does not mean they will not eventually pay the claim.
  • An appeal based on emotion or circumstances will not go very far in the insurance world.
  • Your appeals should be based on one or more of the following (the more direct quotes you can use, the better):
  1. A state or federal law that relates to your case or your healthcare coverage in general
  2. Your insurance policy, using its specific terminology
  3. Documented conversations you’ve had with the insurance company (keep a paper trail–always)
  4. A doctor’s recommendation for treatment (usually can be taken from the doctor’s notes in the patient’s medical record)
  5. Others who have authority to speak on the topic such as your representative or agent at the company/workplace that provided the policy

Some people cite having to appeal several times before they are paid. The insurance company will use details like terminology to reject a claim. For example, developmental delays sounds appropriate, but most insurance companies will deny coverage for that after age two. If that terminology appears anywhere on the doctor’s report, they will often zero in on that and deny the claim, even if there is a more serious diagnosis in the mix. You then have to appeal your claim stating the other diagnoses as given by a doctor, and prove that your policy covers that diagnosis. In this case, it’s a matter of where the person chooses to focus.

Insurance companies know the ins and outs of the law, and they have set responses to certain claims, counting on the fact that a lot of people will not go through the hassle of appealing claims. My advice is that if you have the law, the doctor’s reports, and the policy information to back up your claim, go forward with the appeal. Yes, it takes a lot of work, but it is worth it to get paid money that is your due.

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