Insurance appeals · call recap
The appeals that failed
16 February 202613 attendedHeld by Petra
I run this call once a year because a circle that only counts its wins is running a marketing operation. Thirteen people, six of whom have lost an appeal, two of whom have lost two. We went through them properly. The findings were less about technique than I expected and more about where the wall actually is.
What the failures had in common
Three of the six were plan exclusions, not clinical decisions. No amount of evidence answers an exclusion, because the exclusion is not asking a clinical question. I have started saying that at the first call now: read for an exclusion before you build an evidence pack, or you will spend six weeks answering a question nobody asked.
Two were criteria the member did not meet and was never going to meet on the documentation available. One was a deadline missed by four days.
What came up
What people did next. One moved employer. One was granted on a different indication a year later after a cardiovascular assessment, which is a route that exists and is not available to everybody and should not be treated as a trick. Two are self-funding at a level they described plainly and without embarrassment, which is what this circle asks for. One stopped, and said so, and the room did not treat it as a defeat.
Zeb, who has won one and lost one, said the useful thing: the win took eleven weeks of dull work and the loss took the same eleven weeks, and the only difference was a sentence in a document he had no control over.
Where we left it
With the exclusion check moved to the top of our own method, which I have updated. And with something I want to say to anyone reading this later: losing an appeal is not a failure of your effort or your writing. Sometimes the answer is genuinely no, and the honest thing is to say so and turn to the next question rather than pretending there is always a way through.