Your Health Insurance Claim Was Denied — Here Is What to Do

# Your Health Insurance Claim Was Denied — Here Is What to Do

Receiving a claim denial letter is one of the most stressful experiences in healthcare. You expected your insurance to cover a treatment, and now they are saying it will not. But a denial is not final. In fact, a significant percentage of denied claims are overturned on appeal.

Why Claims Get Denied

Before mounting your appeal, understand why the claim was denied. The most common reasons:

### Administrative Errors - Wrong billing code submitted by the provider - Missing pre-authorisation (the provider did not get approval before treatment) - Claim filed past the deadline - Incorrect patient or policy information

### Coverage Disputes - The service is not covered under your plan - The treatment is deemed "not medically necessary" - Out-of-network provider was used without plan approval - Pre-existing condition exclusion (on non-ACA plans)

### Coordination of Benefits - If you have two insurance plans, they may dispute which one pays first

The denial letter (called an Explanation of Benefits or EOB in the US) must state the specific reason for the denial. Read it carefully — the reason determines your appeal strategy.

Step 1: Check for Simple Errors

Before launching a formal appeal, call the insurer and the provider's billing department. Many denials are caused by simple mistakes:

• Incorrect billing code (CPT or ICD code)
• Typo in your policy number
• Claim submitted to the wrong insurer (if you recently switched plans)
• Missing referral or pre-authorisation that can be obtained retroactively

If the denial was caused by a billing error, the provider can correct and resubmit the claim. This resolves many denials without a formal appeal.

Step 2: Request Your Complete Claim File

You have the right to receive your full claim file from the insurer, including: - The specific policy language they cite for the denial - Any medical reviewer's notes - The criteria used to determine "medical necessity"

In the US, the ACA requires insurers to provide this information. In other countries, check your insurer's obligations — most are required to explain denials in writing.

Step 3: File an Internal Appeal

Almost all insurance plans have an internal appeal process. This is your first formal step:

### How to Appeal 1. Write a formal appeal letter that includes: - Your name, policy number, and claim number - The date of service and the specific denial reason - Why the treatment was medically necessary, citing specific symptoms and medical history - Any supporting documentation

2. Get a letter from your doctor — A detailed letter from your treating physician explaining why the treatment was necessary is the single most powerful piece of evidence. The letter should reference medical literature, clinical guidelines, or standards of care.

3. Include supporting evidence: - Medical records - Lab results - Published clinical guidelines supporting the treatment - Peer-reviewed studies showing the treatment's effectiveness

4. Submit within the deadline — Most plans give you 30–180 days to file an internal appeal. Do not miss this window.

### What to Emphasize - Focus on medical necessity, not financial hardship. - Reference the plan's own coverage criteria and show how your treatment meets them. - If the denial was for an "experimental" treatment, provide evidence that it is standard of care. - Be factual, specific, and professional.

Step 4: External Review (If Internal Appeal Fails)

If the internal appeal is denied, you have the right to an external review in many jurisdictions:

### United States The ACA requires insurers to offer external review by an independent third party. The external reviewer examines your case with no ties to the insurer. External reviews overturn denials approximately 40–50% of the time — much higher than many people expect.

To request external review: - Contact your insurer for their external review process - Or file through your state's insurance department - The review is typically free and must be completed within 45 days (or 72 hours for urgent cases)

### Other Countries - UK: The Financial Ombudsman Service handles insurance complaints. - Germany: Patients can appeal to the Sozialversicherung (social court) for GKV disputes. - Australia: The Private Health Insurance Ombudsman investigates complaints. - International plans: Many have an arbitration process outlined in the policy.

Step 5: Contact Your Insurance Regulator

If you believe the insurer is acting in bad faith — systematically denying valid claims, ignoring appeal deadlines, or violating policy terms — file a complaint with the relevant regulatory body:

• US: Your state's Department of Insurance
• UK: Financial Conduct Authority (FCA)
• EU: National insurance regulators vary by country
• International plans: The regulator in the insurer's home jurisdiction

Regulators investigate patterns of behaviour and can impose fines or corrective action on insurers.

Tips for Maximising Success

1. Appeal promptly — Do not let deadlines pass. The sooner you act, the better. 2. Be persistent — Many people give up after one denial. Those who appeal win a surprising percentage of the time. 3. Keep detailed records — Document every phone call (date, time, representative name, what was discussed). 4. Escalate within the insurer — If the first-level representative is unhelpful, ask for a supervisor or the appeals department. 5. Consider a patient advocate — In the US, patient advocacy organisations can help you navigate complex appeals for free or low cost. 6. Consult a lawyer for large claims — For claims over $10,000, an attorney specializing in insurance law may be worth the investment.

Prevention Is Best

To reduce the chance of denials in the first place: - Always get pre-authorisation for procedures your plan requires it for. - Confirm providers are in-network before appointments. - Ask your doctor's office to verify coverage for non-routine treatments before they are performed. - Keep copies of all referrals and authorisations. - Review your EOB for every claim — do not assume everything was processed correctly.

Bottom Line

A denied claim is not the final word. Appeal the decision, support your case with medical evidence, and escalate if necessary. The system is designed to give you multiple chances to fight for the coverage you paid for — use them.