FixMyClaim

Introduction

Receiving a rejection letter is not the final word—it is the beginning of a negotiation. Insurance companies often rely on the fact that many policyholders will simply walk away after the first "No."

By adopting a persistent, methodical approach, you can navigate the bureaucracy and secure the settlement you are legally entitled to.

Step 1: Analyze the Denial Letter

Before reacting, you must act as a detective. Read the denial letter to find the specific Reason Code. Is it an administrative error, or is it a policy-based rejection?

Administrative: Typographical errors, wrong dates, or incorrect policy IDs.
Contractual: Claims that the service isn't covered under your specific plan.
Clinical: Claims that the treatment was not the "standard of care."

Step 2: Build Your Evidence File

Evidence is the only language insurance adjusters respect. Create a folder (digital or physical) containing:

Phone Logs: Every call to the insurer, including the agent’s name and reference number.
Medical/Technical Reports: Independent assessments that contradict the insurer’s findings.
Policy Highlighting: A printed copy of your policy with the sections that support your claim highlighted in yellow.

Step 3: The First Level Appeal

Draft a formal rebuttal. Do not be emotional; be surgical.

State the claim number and date.
Quote the reason for denial.
Provide the evidence that proves the denial was incorrect.
Set a deadline (e.g., "I look forward to your response within 15 business days").

Step 4: Escalation to the Ombudsman

If the first appeal is rejected, ask for a "Second Level Review" by a different adjuster. If that fails, contact your state’s Insurance Ombudsman or Regulatory Authority. These government bodies exist to protect consumers from unfair practices.

Conclusion

Persistence is your greatest asset. Many successful claims are approved only on the second or third attempt. Stay organized, stay calm, and don’t take "No" for an answer.