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Insurance Claims

Claim Denial and Appeal Process

A policyholder's claim has been denied, and they are calling the insurance company to understand the reasons for the denial and initiate an appeal or dispute process.

Dialogue

Listen and follow along with the conversation

1
Policyholder (Male)
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.
2
Insurance Representative (Female)
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.
3
Policyholder (Male)
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?
4
Insurance Representative (Female)
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.
5
Policyholder (Male)
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.
6
Insurance Representative (Female)
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.
7
Policyholder (Male)
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?
8
Insurance Representative (Female)
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.
9
Policyholder (Male)
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.
10
Insurance Representative (Female)
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.

Vocabulary

Essential words and phrases from the dialogue

claim

A formal request for payment from an insurance company after an accident or loss. In this dialogue, it's used to refer to the policyholder's request for insurance money.

denied

Refused or not approved. Here, it means the insurance company did not accept the claim, as in 'my claim was denied'.

pre-existing condition

A health problem that existed before buying insurance, which might not be covered. It's a key term in insurance discussions to explain why claims are rejected.

policy

The contract or agreement with an insurance company that outlines what is covered. Use it when talking about insurance rules, like 'my policy states coverage'.

appeal

A formal request to review and possibly change a decision, such as a denied claim. In this context, it's the process to challenge the insurance denial.

documentation

Official papers or evidence needed to support a request. Here, it refers to medical reports or letters required for the appeal.

inception

The beginning or start of something, like when a policy starts. It's used formally in insurance to mean 'shortly after policy inception'.

Key Sentences

Important phrases to remember and practice

I just received a letter stating my claim was denied, and I'd like to understand why.

This polite inquiry sentence uses past passive 'was denied' to describe a received decision. It's useful for starting a conversation about a problem, showing how to ask for clarification in formal situations like customer service.

Your claim was denied due to a pre-existing condition that was not disclosed during policy application.

This explanatory sentence uses 'due to' for reasons and passive voice 'was not disclosed'. It's practical for explaining rejections in professional settings, helping learners express causes clearly.

Can you elaborate on what condition they're referring to?

A request for more details using 'elaborate on' (explain in more detail). This is a useful polite question pattern for seeking specifics in discussions, especially when something is unclear.

You absolutely have the right to appeal.

This affirmative sentence uses 'absolutely' for emphasis and 'have the right to' for permissions. It's helpful for reassuring someone and informing about options in service interactions.

The first step is to submit a formal letter of appeal, detailing why you believe the claim should be reconsidered.

This instructional sentence uses gerund 'detailing' after a noun and 'should be' for suggestions. It's a key pattern for giving step-by-step advice, common in procedural explanations like appeals.

We aim to review all appeals within 15 to 30 business days.

This uses 'aim to' for goals and 'within' for time ranges. Useful for setting expectations in business or service contexts, teaching how to discuss timelines professionally.

Thank you for guiding me through this. I appreciate your help.

A polite closing with 'guiding me through' (helping step by step) and 'appreciate' for gratitude. This pattern is essential for ending conversations positively, showing thanks in helpful interactions.