(The following is from a former patient who volunteered this information in 2016; modify it to suit your particular needs)
(enter your letterhead, and date)
To Whom It May Concern:
I am writing to you for an insurance claim in which my husband and I had to pay for because of a lack of capability of the doctors of (enter name of your insurance carrier) to cure me despite many appointments and treatment attempts.
In contrast, we spent $(enter your total cost) out of pocket for treatment at the Women’s Therapy Center in NY, including flight, hotel, and the treatment itself, and SUCCESSFULLY left their two-week program completely cured.
Women’s Therapy Center cured me in 2 weeks; your providers spent two years of my time, energy, and money and failed me. The following were my expenses, and my justification for this insurance claim:
A list of your healthcare providers who treated but failed to cure me (list their name, credentials, and description of services provided):
- XXXXX XXXXX, PT
- XXXXX XXXX MD
Costs of travel and treatment:
- Cost of treatment at Women’s Therapy Center:
$(enter amount off your invoice) to Dr. Ditza Katz
$(enter amount off your invoice) to Dr. Ross Lynn Tabisel
- Total hotel stay: $(enter amount off receipts)
- Total car rental: $(enter amount off receipts)
- Total taxi fare: $(enter amount off receipts)
- Total airfare: $(enter amount off receipts)
Total cost of treatment + travel = $(enter amount totals), excluding meals.
JUSTIFICATION for this claim for out-of-netwrok reimbursement:
I was diagnosed with vaginismus and vulvodynia in August of 2012 and was NOT able to complete a pelvic exam and pap smear because of this condition until August 18th, 2016 subsequent to my time at WTC. I was suffering from vaginismus and was unable to tolerate gynecological examination and vaginal ultrasound, limitations that may have put me under medical risks.
Several of your healthcare providers thought I had sensitive skin and prescribed 3-4 different types of topical steroids for my vaginal area, which was the incorrect diagnoses and treatment plan. Multiple other of your doctors wanted to put me under general anesthesia to preform a routine pelvic exam. This is against my ethical and emotional standards to be forced into pelvic examinations under anesthesia when treatment was readily available from Dr. Ditza Katz, PT, PhD and Dr. Ross Lynn Tabisel, LCSW, PhD from the Women’s Therapy Center in New York.
After NUMEROUS failed physical therapy sessions, Dr. (enter name/s, credentials, etc.) preformed Botox injections and a pelvic exam under general anesthesia on July 27th, 2015. The process was humiliating before, and painful afterwards, when I endured 15 days of continuous bleeding. I then moved to another state, where I started treatment with (enter name/s, credentials, etc.) on August 26th 2015. I had 20 visits with that provider with completely unsuccessful results; again, (enter name of insurance carrier) was unable to cure me.
I had no choice but to look outside of (enter name of insurance carrier) as my treatments were not consistent or effective in treating my condition.
Also, (enter name of insurance carrier) did NOT have an adequate mental health treatment for my condition, which they admitted to this during my appointments.
One of your doctors told me that I was the ONLY patient that she was not able to successfully treat. Another of your doctors also told me I was making enough progress and that she didn’t really want to see me in office anymore as she thought I was on the way to being cured.
I was crushed, and I felt that I was given up on. I learned that vaginismus is a complex condition and, to date, there are few clinical trials to turn to for efficacious treatment options. I had to find treatment outside of (enter name of your insurance carrier) in order to get my life back.
I found the Women’s Therapy Center in Plainview, New York, where they offer a unique concurrent treatment that addresses the physical and emotional aspects of the disorder under the same roof. In addition, Dr. Katz’s experience as a physical therapist specializing in the treatment of vaginismus exclusively is different than local therapists who provide physical therapy within the larger realm of women’s health and pelvic pain. More importantly, systematic desensitization has been shown to be most effective when it is demonstrated and learned in a concentrated and controlled environment; something that (enter name of your insurance carrier) DOES NOT offer.
And it worked. I am cured. Unlike your failure, I was successful through the Women’s Therapy Center’s two-week program.
Because these services were not available to me by you, I am seeking reimbursement for my out-of-network treatment expenses, which are LESS costly in total than the NUMEROUS treatment I had in-network in the past, plus those I would have had to still have in the future had I not found the Women’s Therapy Center!
Attached are receipts for travel, treatment, and hotel costs.
Thank you for your time,
(enter your name and signature)