Question:
Can someone please help or give me ideas on a appeals letter to my insurance company?

I really don't know what my insurance is looking for in an appeals letter since I was denied. I have United Health Care EPO. Does anyone have any ideas? PLEASE!    — T. B. (posted on September 8, 2003)

September 8, 2003
First, is your policy with you or your spouse's employer, If so go online to your benefits, or look at your actual SPD (summary plan descriptions) that every employee should have or have access to (on line) then go to the section that has exclusions to see if your wls is listed there as not covered. Be aware that the language your company has chosen to use for exclusions will be tricky (no insurance wants to pay for expensive surgery) and remember that unless the insurance company sees that it is in their best interest they won't budge. So your letter has to address the exact wording of thier exclusion, to show YOU know that this surgery is covered, blah blah blah, do NOT write a personal type appeal letter: trying to elicit sympathy. They do NOT respond to that, in fact they want you to beg and cry. They only will respond if they see that you know what you are talking about, you have the back up resources and so on. Point out that this surgery is to save you life, that it will most probably reverse your co-morbities:and be sure to list them: like GERD< Planters Facietis, hypertension, hi cholesterol, depression, Gall bladder disease, diabetes, and if you have a family history of hypertension, diabetes this will prevent you from developing these diseases which in turn is cost effective to them. Point out and list all the Dr's that you have seen that support this surgery, including your bariatric surgeon. I hope this is helpful. As long as you send a letter that addresses the issue of it is in their best interest to pay for this surgery and give them all the reasons why Again don't beg, don't make it an emotional or personal letter. To the point with lots of references (medical)and like you are in charge. JK in TX
   — jackie K.

September 8, 2003
t. brown, I forgot to ask what did your appeals letter say??? They have to give you the specific reasons for denying you not just that they are denying you. It is the law. You can also go to your state insurance department and file an complaint against them if you indeed should be covered for this procedure. JK in TX
   — jackie K.