Going through the appeal process with a medical, dental, or auto insurance company can be long and frustrating. But there is a way to win an insurance appeal that they don’t want you to know about.
I’ve won appeals with all three of these insurance types. Here’s the story of my latest victory with a dental insurance appeal. The dollar amount isn’t much but the process is the same one I’ve used for other appeals. I’ll start by giving you some background and a few tips.
When a claim or appeal has been denied, the first thing most people do is call the toll-free number on their insurance card. They explain the unfairness to a customer service representative. Many people get irate, which is a huge mistake. I’ll explain why later. The representative seems to listen carefully (they are usually searching for a response on their computer) and then skillfully explains why the insurance company is not responsible and why you are.
As you can imagine, insurance company customer service representatives are very well-trained. They learn how to “handle” customers, pay out as little as possible, and stay clear of any legal entanglements. Their authority to make decisions on a claim or an appeal is usually nonexistent or very limited.
Based on what I just said, you probably think that I feel that talking to a customer service representative is a waste of time. Actually, it’s a very good investment. Here’s why.
- You might solve the problem with one call.
- You can learn about the interworkings of the insurance product and the company itself with a series of tactical questions.
- The representative can point the way for filing an appeal or a challenge to the appeal.
- The representative can give you the names and contact information of the decision-makers within the department and division heads within the company.
To get the customer service representative to work for you and provide needed information you must be respectful, polite, and charming. You can describe your frustration tactfully, but never get mad at the representative. And never, ever threaten them or the company in any way.
If you consider all the irate customers that a representative must deal with every day, your pleasant approach will be a welcome relief. They’ll want to stay on the phone with you forever!
If you don’t get a good vibe from a representative, they seem incompetent, or uncooperative, just end the call and call back. If you get a representative who you click with, is very cooperative, but sounds unsure about key information, call back to verify it with another representative.
In late November, my health insurance company offered a dental plan for the first time that would become effective on Jan 1. (I have an individual policy.) This announcement was included in a letter about a small rate increase. Attached to the letter was a page with a table showing highlights of the dental plan. There was no phone number for the dental insurance company or information on where to find the list of participating dentists. Although the health insurance company owns the dental insurance company, they are separate entities, as I later learned.
So I called the phone number on the letter which was my health insurance company’s customer service department. The representative knew about the new dental plan and was willing to answer my questions, but seemed to have limited knowledge about it. My most important question was whether my current dentist was in the network. Although the representative checked and said yes, their lack of confidence concerned me so I talked to two more representatives to confirm.
I also called my dentist who said that they were a provider for my health insurance company but were not familiar with the relationship with the new dental plan.
Since the last representative I spoke to was a supervisor, and the one to whom I was to send the dental plan enrollment form, I felt confident that my dentist was in the network. After I confirmed my enrollment in the dental plan on the first working day in January, I made an appointment with my dentist for a cleaning. There was a three-month waiting period, so I made it for April 2.
I went to my dentist on April 2 with my shiny new dental insurance card in my wallet and my hygienist did another magnificent cleaning. Yes, she is that good. Afterward, I handed an office staff member my card. She called the number on the back and then reported that they were not in the network for that particular plan. So I had to pay the $70 fee with a credit card. I wasn’t happy. 🙁
Naturally, I called the same customer service number at my health insurance company to explain what happened. The representative said I’d have to take up the matter with the dental insurance company. So I called them and was told I’d have to file an appeal in writing via postal mail.
Since I had a very cooperative representative, I took the opportunity to learn about the product, company, and appeals process so I could write a convincing letter. Since I’d been through countless customer service (many industries) victories in the past, I wrote what I thought was an outstanding letter. So I felt confident I’d win. But guess what, I lost. It was denied. I wasn’t deterred though. This is where most people give up.
The next thing I did was to call the person who handled my appeal. My goal was to answer any issues that were preventing her from approving it. I was “in the zone” when I spoke with her. The discussion went very well. In the end, my direct appeal, of the appeal, was unsuccessful. This is where the few who decided to fight, surrender – to the insurance company.
I gained a lot of valuable information from that appeals case manager. Although she didn’t say it directly, she suggested in a half-joking way that I should take up the matter with my health insurance company since they offered the dental plan.
I decided to call the customer service department at my health insurance company to get contact information for the person who signed the letter offering the new dental plan. This is only the first half of “the secret.” Her title had the word director at the front of it so I knew she had the authority to turn this thing in my favor.
I called her office directly and was handed over to an assistant. That was of no concern to me, as I knew that whatever I communicated to the assistant would be conveyed to the director. I knew this because I would present the issue in a way that would show that this was a serious matter. I don’t mean through dishonesty or exaggeration. I mean by explaining the problem from their point of view. Specifically, I would describe how the letter offering the new dental plan and the training given to customer service representatives was lacking crucial information. I also knew that the assistant would likely give the matter more attention than her boss would. In addition, her boss would have probably given her the project, but this way I would be working with her directly.
My conversation with the assistant went superbly. She asked me to email her a letter in PDF format detailing the appeal and attach any documentation I had like the bill from the dentist. I put it all together on the same day and sent it to her in a zip folder. This time I felt totally confident that I’d win.
A couple of days later a received a very corporate and legally sensitive email explaining why I had been denied again! I was blown away. The king of customer service successes had failed again! This is where even the most hardened warriors give up. Only the eccentric ones who are driven by principle, like me, go on.
I regrouped, reread all the correspondence from the beginning, and wrote a new letter that used bullets to highlight key points. I didn’t point blame at individuals, but I did factually describe the failures at their end that led to the problem. I sent this letter to them as a reply to their email about being denied.
Here’s what I believe led them to seriously reconsider my appeal. Here are the actual words I included at the bottom of my email reply to their denial.
“I want to take this matter to the highest level possible. Please provide me with the name, title, phone, and email of the person who oversees both (medical and dental) organizations.”
This may sound like it’s a treat, but it’s not. There is no threatening language in that statement or any part of the letter. And I truly wanted that information because I was going to do it. But I suspect that the director, and perhaps her superior, saw how my escalation of this matter could reveal to upper management how their introduction of the new dental plan was poorly managed.
I got a reply from the assistant the next day. The carefully worded email full of legal jargon and procedural explanation said that my appeal had been reconsidered on their behalf and approved! 😀 It went on to say that a check for $70 would be sent directly to me shortly. I immediately sent a reply expressing my appreciation and thanking her for all her help.
$70 dollars isn’t much, but the method to succeed is the same regardless of the amount. It may take more time and a step or two further, but the strategy is the same. Here’s a recap.
- Be respectful, polite, and charming.
- Be tactful, diplomatic, and resourceful.
- Plan your approach before calling.
- Contact customer service first.
- Ask questions to learn as much as you can.
- Challenge appeals repeatedly.
- Go up the chain of command.
- Establish a never give up attitude.
Hope this helps you win your insurance appeal.