You may think that you know what an appeal is. In order to win your appeal, you will have to let go of that notion. The word “appeal” means “To earnestly request; to arouse a sympathetic response.”
Indeed, this is the way most people approach their appeals. The insurer is the powerful one. I am the small powerless patient. All that I can do is “earnestly request,” and try to “arouse a sympathetic response.”
Good luck with that. Take that approach, and you just lost your appeal.
The purpose of an appeal is NOT …
- To convince your insurer that you need this treatment to save your life, or to improve your quality of life.
- To describe the pain and suffering that they have put you through.
- To point out how unfair this process is.
Insurance appeals are a strategy game—with the highest possible stakes. Let’s take chess as an example.
Do we win a chess match by grabbing the chess board, and clobbering our opponent with it? No. We win by keeping a cool head, focusing like a laser beam on our opponent, and staying one move ahead of him.
The minute you get emotional, you lose.
I have seen many first-, second-, and third-level denial letters in my time. The insurer will seize on any “feeling word” that you use in your appeal, and use it to deny your treatment again: “We considered your very moving speech. However, this is not a covered benefit, etc., etc.”
They have heard every sob story in the book, yours and mine included. Tragic tales not only do not make them approve treatments … they are totally desensitized to them, and they believe that emotion should play no part in medical decisions.
Emotion will only entrench them in their denial. A cool, professional approach will throw them off their game.
In order for your appeal to win, it will have to be purged of all emotion. It will present a mountain of facts and scientific evidence to prove your every point. Your appeal is going to be different than the run-of-the-mill appeal. You are going to prepare a document the like of which they have never seen before, and you are going to beat them at their own game.
An Appeal Is a Strategy Game
The treatment that you are asking for is probably not mandated, approved, or considered standard of care by your insurance company.
They have no intention of paying for it, and they have plenty of official-sounding reasons for their denial.
The insurance company doesn’t have to do anything just because you ask, and they don’t have to pay for anything that they have denied. They are bigger than you are, and they have one hundred lawyers to refute your every argument.
You, on the other hand, are facing a life-threatening disease. You are terrified, overwhelmed, and exhausted. You may have no money, no job, no contacts and no influence. What strategy are you going to adopt, to overcome this bastion of bureaucratic might?
Your lifesaving appeal is a masterpiece of persuasive expository prose. While it is filled with facts, your appeal is a fiction—with you as the main character.
You will create a winning persona for yourself. You are going to pretend to be somebody else. Somebody cool, commanding, and confident.
When I wrote my own appeal, I pretended to be a combination doctor/attorney/ insurance executive. When I write an appeal for somebody else, I adopt their name, take on that commanding personality. The persona that I use for this appeal is as cool as a cucumber. He/she has mastered insurance company propaganda, throws legal terms around like a judge, and shows no fear of insurance companies.
When you write your appeal, leave all fear behind. You are now large and in charge.
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Copyright 2010, The Carcinoid Cancer Foundation and Laurie Todd.