What to do if your insurer 'lost' your appeal

You call at day 45 and the plan says "we have no record of your appeal." This is more common than it should be, and it is why we tell every buyer to send certified mail with Return Receipt. Here is the fix.

Do not repeat the appeal

The temptation is to say "no problem, I will send another one." Do not. That creates two possible interpretations of the same appeal and starts a new clock, giving the plan another 60 days. Instead, prove delivery of the first one.

What to send

A short letter noting:

• The date the plan received your original appeal (from usps.com tracking)
• The tracking number and a printout of the tracking page showing "Delivered"
• The green card image or PDF if you have it
• A copy of your original appeal
• A demand that the plan locate the file and issue a decision on the original clock

Sample letter

Send certified mail to the same appeals address.

"Regarding my appeal of claim [claim number] for [member name], your representative told me on [date, call reference] that your office has no record of my appeal. Please find enclosed proof of delivery to your appeals office on [delivery date] under USPS Certified Mail tracking number [tracking number]. Enclosed is a full copy of the appeal for your convenience. Please treat this as a demand that the review resume under the original deadline of [regulatory deadline, e.g., 60 days from [delivery date] under 29 CFR 2560.503-1(i)(2)(iii)(A)]. If a written decision is not issued by [deadline date], I will proceed under deemed exhaustion and file for external review and, if applicable, a complaint with the state insurance department and the US Department of Labor."

Save the escalation

The letter above is stronger than it sounds. It:

• Documents that the plan admitted losing the appeal
• Documents your proof of delivery
• Cites the regulatory clock
• Names the escalation paths in advance

Most plans, faced with that letter, find the file within a week.

If they still cannot find it

• Ask for the appeals office fax number and fax the entire packet, keeping the fax confirmation page
• Ask for the appeals office secure email address (some plans have one) and email the packet, requesting a read receipt
• If the plan will not accept any of the above, file a complaint with your state DOI and, if ERISA, the DOL EBSA

For ERISA plans specifically

Under 29 CFR 2560.503-1(l), a plan's failure to establish or follow claims procedures consistent with the regulation means you may treat administrative remedies as exhausted. That means:

• You do not need to wait for the plan to "find" the appeal
• You can file for external review immediately
• You can file suit under ERISA section 502(a)(1)(B)

An ERISA attorney will be interested in this fact pattern. See When to hire an ERISA attorney.

For Medicare Advantage

If the plan cannot process your reconsideration within 30 days for standard pre-service (or 60 days for standard payment), the case is auto-forwarded to the Independent Review Entity (IRE) under 42 CFR 422.590(g). Call 1-800-MEDICARE to trigger the forward if the plan is stonewalling.

Prevention

Every appeal we help you draft comes with a mailing instruction sheet that says certified with Return Receipt. Follow it. The $6 to $10 you spend on postage is the strongest single dollar you spend on the whole appeal.