Features September 2015 Issue

Filing an Appeal

Insurance companies are in the business to make money, and anything they can legally deny, they will. However, that doesn’t mean they’re always right. You can file a letter of appeal with your insurer, but you need more than a stern letter. You need proof that you’re right. The evidence you need depends upon the disagreement and your contract.

If they’re denying payment for a treatment because they considered it not medically necessary, or experimental/investigative, consider sending them proof to the contrary, such as statements from other veterinarians and veterinary groups that support your case, research papers that support the treatment, and even case histories of dogs with similar illnesses who recovered successfully with the treatment you chose for your dog.

If the plan you have chosen has a “benefit schedule,” it will be very difficult to win an appeal because you have already in essence agreed to accept specific, set reimbursements for any care needed by your dog. If you have a U&C contract, you’ll need to include tangible proof that the amount charged by your veterinary is “reasonable.” Consider sending them Internet searches that show similar charges, examples of other cases and fees similar to your bill, and cost-of-living comparisons, if you suspect the U&C didn’t take your geographic location into consideration.

Be prepared to fight. Rarely do you win on first appeal; instead, you will likely receive an initial rejection, repeating your contract provisions. If your case has merit, most insurers will give in with your second letter. However, you may have to appeal to your state’s insurance commissioner. Some states require a small fee (about $50) before they will examine your appeal, but it may be money well spent, as most companies want to avoid being frequently scrutinized by the state and they may give in to your request almost immediately upon receiving news of your appeal at this level.

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