理赔被拒及申诉流程

Hello, my name is David Miller. I'm calling about claim number LC-2023-54321. I just received a letter stating my claim was denied, and I'd like to understand why.

Good morning, Mr. Miller. I'm Sarah from the claims department. Let me pull up your claim. One moment, please. Okay, I see here that your claim was denied due to a pre-existing condition that was not disclosed during policy application.

A pre-existing condition? I'm not aware of any such condition that would impact this specific claim. My policy clearly states coverage for this type of incident. Can you elaborate on what condition they're referring to?

Certainly, Mr. Miller. The denial letter refers to a medical report from March of 2022, indicating a chronic back issue. Since your current claim is for a similar back injury that occurred shortly after policy inception, it's being categorized as a pre-existing condition.

I understand. However, that was a minor strain from an old sports injury, fully recovered. This current injury is completely separate, from a recent accident. Is there a way to appeal this decision? I believe there's been a misunderstanding.

Yes, Mr. Miller, you absolutely have the right to appeal. The first step is to submit a formal letter of appeal, detailing why you believe the claim should be reconsidered and providing any supporting documentation, like recent medical reports proving the new injury is unrelated. We recommend including a cover letter with your claim number and contact information.

Okay, so a formal appeal letter and supporting documents. Where should I send this? And what's the typical timeframe for an appeal to be reviewed?

You can send the appeal to our Appeals Department at the address listed on your denial letter. We aim to review all appeals within 15 to 30 business days, though complex cases might take longer. Once reviewed, you'll receive a detailed letter outlining the outcome.

Alright, that clarifies things. I'll gather the necessary documents and send the appeal as soon as possible. Thank you for guiding me through this, Sarah. I appreciate your help.

You're very welcome, Mr. Miller. If you have any further questions during this process, please don't hesitate to call us back. Have a good day.