返回情境
Insurance Claims

Claim Denial and Appeal Process

理赔被拒及申诉流程

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.

投保人的索赔被拒，他们致电保险公司以了解拒绝的原因并启动申诉或争议流程。

对话

聆听并跟进对话

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.
您好，我叫戴维·米勒。我打电话是想询问理赔号LC-2023-54321。我刚收到一封信，说我的理赔被拒了，我想知道原因。
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.
早上好，米勒先生。我是理赔部的莎拉。请稍等，我来查一下您的理赔。好的，我看到您的理赔被拒，理由是投保时未披露的既往病史。
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?
既往病史？我不清楚有什么既往病史会影响这项具体的理赔。我的保单明确规定涵盖此类事件。您能详细说明他们指的是什么病症吗？
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.
当然，米勒先生。拒赔信中提到一份2022年3月的医疗报告，显示有慢性背部问题。由于您目前的理赔是针对保单生效后不久发生的类似背部损伤，因此被归类为既往病症。
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.
我明白了。但是，那只是旧运动伤造成的轻微拉伤，已经完全康复了。这次的伤是最近一次事故造成的，完全不同。有没有办法申诉这个决定？我认为存在误解。
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.
是的，米勒先生，您当然有权提出申诉。第一步是提交一份正式的申诉信，详细说明您认为理赔应重新考虑的原因，并提供任何支持文件，例如证明新伤无关的最新医疗报告。我们建议您附上一封附函，注明您的理赔号和联系方式。
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?
好的，那就是一份正式的申诉信和支持文件。我应该寄到哪里？申诉通常需要多长时间才能得到审查？
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.
您可以将申诉寄到您拒赔信上列出的我们上诉部门的地址。我们的目标是在15到30个工作日内审查所有申诉，尽管复杂的案件可能需要更长时间。审查结束后，您将收到一封详细的信件，说明结果。
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.
好的，这下清楚了。我会尽快收集必要的文件并提交申诉。谢谢你指导我完成了这些，莎拉。我很感谢你的帮助。
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.
不客气，米勒先生。在此过程中如果还有其他问题，请随时给我们回电。祝您有美好的一天。

词汇

对话中的必备词汇和短语

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.

事故或损失后向保险公司提出的付款正式请求。在本对话中，用于指代保单持有人对保险金的请求。

denied

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

被拒绝或未获批准。在此，它意味着保险公司没有接受索赔，例如'我的索赔被拒绝了'。

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.

在购买保险之前就已经存在的健康问题，可能不予承保。这是保险讨论中的关键术语，用于解释索赔被拒的原因。

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'.

与保险公司签订的合同或协议，概述了覆盖范围。在谈论保险规则时使用，例如‘我的保单规定了覆盖范围’。

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.

正式请求审查并可能更改决定，例如被拒的索赔。在此上下文中，它是挑战保险拒赔的过程。

documentation

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

支持请求所需的官方文件或证据。在此，指上诉所需的医疗报告或信件。

inception

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

某事的开始或起始，例如保单开始时。在保险中正式用于表示“保单生效后不久”。

关键句型

需要记住和练习的重要短语

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.

这个礼貌的询问句子使用过去被动语态 'was denied' 来描述收到的决定。它有助于开始关于问题的对话，展示如何在客户服务等正式场合请求澄清。

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.

这个解释性句子使用 'due to' 表示原因，以及被动语态 'was not disclosed'。它在专业环境中解释拒绝很实用，帮助学习者清楚表达原因。

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.

使用 'elaborate on'（更详细解释）请求更多细节。这是一个有用的礼貌问题模式，用于在讨论中寻求具体细节，特别是当某些事情不清楚时。

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.

这个肯定句使用‘absolutely’来强调，使用‘have the right to’来表示权限。它有助于在服务互动中安慰某人并告知选项。

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.

这个指导性句子在名词后使用了动名词“detailing”，并使用“should be”来表示建议。这是提供逐步建议的关键模式，在像上诉这样的程序性解释中很常见。

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.

这使用了 'aim to' 表示目标，以及 'within' 表示时间范围。在商业或服务环境中设置期望很有用，可教导如何专业地讨论时间表。

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.

使用“guiding me through”（逐步帮助）和“appreciate”（表示感激）的礼貌结尾。这种模式对于以积极方式结束对话、在有帮助的互动中表达感谢至关重要。