Fillable Letter Template for Healthcare Coverage Appeal

If you wish to receive treatment from a private healthcare practice (such as a psychiatrist or psychotherapist) who doesn't have a contract with your insurance company , you may only receive partial reimbursement for the costs. This limited reimbursement results in an out-of-pocket payment of 25-45% of the treatment costs. This can quickly amount to several hundred euros per month.

According to healthcare law, this out-of-pocket payment cannot be so high that it prevents you from choosing your preferred healthcare provider. Recent Supreme Court rulings have confirmed that a 50% out-of-pocket payment is too high and that insured persons are entitled to higher reimbursement. However, the exact amount an insurer must reimburse has not been established. You can use this letter to request higher coverage.

How to use this letter:

• Open this HTML document in a web browser.
• Fill in all the fields in the sections "Personal Information" and "Insurance Information".
• In the section "Additional Information", enter the name of the practice where you wish to receive treatment.
• In this section you can also specify the maximum monthly amount you can contribute. Note: A monthly 'out-of-pocket' payment of €50 means you'll contribute €600 annually, in addition to your deductible.
• Copy the letter and send it to your insurance company. Clicking the button below the letter will copy the completed letter, which you can then paste (ctrl-v) into a document or website form. Some insurers allow you to submit this letter through their complaint form on their website.
• Wait for your insurer's response, and if necessary, request a follow-up if they haven't responded within 5 business days.
• If the insurer indicates that you are not entitled to higher reimbursement, or if you can't resolve the issue with your insurer, the healthcare authority recommends taking the matter to the SKGZ dispute committee or court.

Important notes:

• This letter template is specifically designed for treatment at a private mental healthcare practice.
• You have the right to choose your healthcare provider, regardless of your insurance type.
• You can use this letter if the expected out-of-pocket costs prevent you from starting treatment.
• Your insurer may request additional information. Ask for a written explanation of their policies and rules.

This letter template is licensed under the Creative Commons Attribution-NonCommercial 4.0 International License (CC BY-NC 4.0).

When using this letter template, you must:

• Include attribution to https://contractvrijepsychiater.nl
• Reference the CC BY-NC 4.0 license
• Indicate if any changes were made to the original template
• Not use this template for commercial purposes