It certainly isn’t an uncommon occurrence. An offer on a submitted case comes back worse than you were expecting. Or worse than you hoped. Or, heaven forbid, as a decline. While you know not every case comes back with a positive outcome, you’ve reviewed the particulars and feel a better offer could still be placed. What’s your next option?
A case isn’t only declined on medical grounds. It’s an easier explanation when an attending physician statement or lab findings lead to a rating or declination. Sometimes financial considerations sink a case. It could be habits, sensitive information or missing information. But particularly on a medical appeal, it helps to be on top of your game and be able to converse intelligently on the positive factors in the case and why you feel there should or could be a different outcome.
You don’t have to be an underwriter or a physician to discuss a case you submitted. When you call for details, both underwriter and medical officer will give you as clear a reason for the decision as can be made while preserving doctor-patient confidentiality. Applicants certainly wouldn’t want you discussing sensitive medical history behind their backs. On the other hand, often the decision was made on admitted history. Or perhaps you were one who facilitated the sending of the records. You’ll have a good idea of what the problem was.
Have the facts on your side. You may know an applicant is a cardiac risk, for instance. But you also know he takes pristine care of himself, doesn’t smoke or drink, and is always the one to order salad at the nearest carnivore restaurant. Put these in writing, send them, and then call to discuss. Tell us what’s more favorable about this case than we could know only from papers and records. If there are other physicians an insured has seen, get additional information that helps the case. If the client is willing to do additional testing to get a lower rating, not only volunteer that, but ask the underwriter what result would make him more comfortable if it came back favorable. And if a personal doctor has information that is enlightening, get it in writing to be part of the file. Doctor to medical director or doctor to underwriter conversations are generally counterproductive, as differences between clinical medicine and insurance medicine are not easily explained in a simple phone call.
To make an appeal as successful as possible, know what you are asking for and know if your request is a reasonable one. Getting a decline changed to a standard generally doesn’t happen. Decreasing the offer to something you can more easily place does. Know your client. Don’t promise an unattainable result when what you might have put forward on a realistic basis is more likely. A client may be irate when a standard shows up instead of preferred—to him it seems like a rated case, as the amount is higher than what they were expecting. But almost all companies make clear what their preferred criteria is—and build, blood pressure or cholesterol clearly out of guidelines isn’t going to get preferred. Thinking a repeat blood test will turn a diabetic into a nondiabetic isn’t going to happen. But if a client didn’t fast, a number is close, or is not consistent with other numbers in the charts, a repeat may be a much more reasonable request.
Sometimes medical findings are what they are and business considerations are necessary. For instance, a small change in a key man rating that would bring other valuable partner business with it. A competing company made an offer close to the one you received and you could place additional business if only your preferred company would match the offer. Underwriters are fond of saying that “underwriting is an art, not a science,” and in those cases a company may match the competition because it makes business sense to do so. In those cases, have the competing offer or details of the offer in hand—no underwriter takes kindly to being bluffed into competing with an offer that isn’t real (and generally has a long memory for the next time a similar situation comes up).
An appeal is a real tool when used wisely, and not infrequently it is granted. But you don’t want to be a serial appealer, screaming for a re-look at every case you get back, no matter whether the offer is reasonable or not. The “cry wolf” syndrome will make it so even your legitimate requests are bypassed. When you know what you need and you feel that another look can yield an outcome more favorable, or a rating that is more placeable, coming with as much supplemental or new information as you can provide gives both underwriter and doctor a reason to reconsider a case more favorably. When push comes to shove and an appeal isn’t going to yield a positive outcome in the short term, ask when the case can be reconsidered and what you would need to bring to get the offer you’re hoping for. After a waiting period, or when new information comes up favorable to the client, the process is much more expedited and may lead to a successful placement.
