MODULE 4: ADVANCED CHALLENGES

Denials & Appeals

Lesson 4.1 - The Billing Blueprint: Mold Edition

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Not All Denials Are Final

Mold claims get denied more often than water claims.

But many denials can be appealed successfully
if you understand why and how to respond.

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Common Denial Reasons

"Mold exclusion" - Policy excludes mold (check for exceptions)
"Pre-existing condition" - Mold existed before loss
"Not from covered peril" - Causation dispute
"Maintenance/neglect" - Homeowner failure to maintain
"Exceeds policy limits" - Limit exhaustion (different strategy)
"Insufficient documentation" - Easiest to fix

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When Is an Appeal Viable?

Appeal IS Viable

• Denial based on incorrect facts
• Missing docs you can provide
• Coverage interpretation is arguable
• Clear connection to covered loss

Appeal NOT Viable

• Clear policy exclusion, no exceptions
• Obvious pre-existing condition
• Undeniable maintenance neglect
• Limit already exhausted

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Building Your Case

Start with denial letter - what exactly did they say?
Gather evidence that contradicts their reason
For pre-existing: timeline evidence, photos before/after
For causation: documentation linking water loss to mold location
For maintenance: evidence loss was sudden, not long-term neglect

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Appeal Letter Structure

Identify - Claim #, policy #, denial date
State their reason - Show you understand their position
Address it specifically - Present your evidence
Reference policy language - Quote supporting sections
Request specific action - "Reverse denial and approve"
Set deadline - "Please respond within 15 business days"

Tone: Professional and factual. Not angry. Not apologetic.

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Evidence by Denial Type

Pre-existing: Timeline photos, when water loss occurred, when mold discovered
Not from covered peril: Moisture mapping, mold location matching water path
Maintenance: Evidence of sudden failure vs. chronic neglect
Documentation: Provide what's missing, reorganize, explain

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After Submitting Appeal

Day 7: Confirm receipt, ask who's assigned
Day 14: Request status, when to expect decision
No response? Escalate - ask for supervisor
Still denied? Customer can file state complaint or hire public adjuster

Document every communication. Dates, times, who you spoke with.

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Know When to Stop

Be realistic.

Fighting unwinnable appeals wastes time and frustrates everyone.

Focus energy on appeals you can actually win.

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Key Takeaways

Know the specific denial reason before responding
Assess whether appeal is viable
Build case with evidence contradicting their reason
Write professional appeal letter with structure
Follow up systematically, escalate if needed
Know when to stop fighting

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Coming Up Next

Lesson 4.2: Limit Exhaustion

When insurance has paid their limit
Collecting the customer balance
Payment arrangements
Collection strategies

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MODULE 4: ADVANCED CHALLENGES

End of Lesson 4.1

Denials & Appeals

Action Item: Review a past denial. What was the reason? Was appeal viable?

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