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  • Writer's pictureInge Johnstone

Appealing Your Denied Health Insurance Claim

Updated: Nov 20, 2023

Unfortunately, too many Americans find themselves on the wrong side of the denial of a health insurance claim. When this happens, people can be left holding the bill for thousands, tens of thousands, or even hundreds of thousands of dollars in claims. In addition to calling an experienced health insurance attorney, here are some you can do if you find yourself in this situation.

First, preserve all written communications and notes of phone conversations with the insurance company. Often, the denial of the claim will come in the form of an explanation of benefits form (an EOB). Make sure that you hold on to any of these forms that you receive. Pay attention to the explanation given for the denial and any time limits set out in the form. 

Next, make sure that you have a complete copy of your policy. If you have a group policy, you likely have a copy of a summary of benefits or benefits booklet provided by your employer. However, you should ask your employer for a copy of the group policy itself. This may also be called the contract.

Read through your benefits booklet and contract carefully and compare the reason given for the denial with the policy language. Then, look for the language in the policy that deals with deadlines for appealing health insurance claims. If your policy is an ACA compliant policy, or a group policy through your employer, it will provide language for an appeal. This language will describe how to appeal, your appeal deadline, and what to do after your appeal is decided. The document will also give a time limit for the company's decision on your appeal. Make note of all of these guidelines. They must be followed. 

Also, the policy likely will contain information about documents that you can request to get more information about why the insurance company denied your claim. If after reading your policy, you still disagree with the insurance company’s denial, make sure to send a written request to the company asking for information on why the company denied your claim. This information may include: copies of any documents that the insurer relied on in reaching their decision, copies of any documents that were submitted, considered or generated by the insurance company in reaching their decision, copies of any internal rules, guidelines or protocols that the insurance company relied on in reaching their decision, a statement explaining any medical or scientific principles that the insurance company relied on, and the name of any healthcare professional that the insurance company obtained advice from in connection with the claim denial. Try to send this request for information as soon as possible so that you will have it for your appeal.

Make sure to speak with your doctor and other healthcare providers and enlist their help in drafting letters and providing other information. For instance, if your insurer claimed that a certain procedure was not medically necessary, cosmetic, or experimental, a physician's letter explaining the procedure, why it was necessary, and the medical science supporting it can be helpful to your appeal. You will also want to ask your doctor if they know of any medical journal articles discussing your procedure.

Go online and look for medical journals on your own. One good source is PubMed, a website provided by the National Institute of Health. This website provides abstracts of medical articles and sometimes links to the full articles themselves.

Take pictures if applicable. Before and after pictures of the treatment can be helpful and demonstrate why the treatment was important.

Look online for other people that have had claims denied for the same reason that you have. They may be able to point you to helpful resources. In addition, you may find support groups that can also put you in touch with people going through the same problem you are or that have helpful information.

After you have gathered information supporting your appeal, you will need to draft your appeal letter. In it, you will want to clearly explain why the charges that the insurance company denied are covered by your health insurance policy. You want to refer to the applicable parts of the policy and to the other materials that you have attached. Be sure to retain a copy of everything that you send to the insurance company, along with proof of mailing. Also, make sure you follow the insurance company’s mailing requirements exactly.

If you follow these guidelines and any requirements listed in your policy, you will increase your odds of getting the insurance company to pay your claim. However, if you have a serious health claim that has not been paid, you should contact a health insurance policyholder’s attorney. A health insurance policy attorney can help you make sure that you have gathered the right information, met all deadlines, and given yourself the best chance to win your claim. In addition, if you miss a deadline or do not get the right information to the insurance company, you might cut-off your ability to recover.

Here are some additional resources on the web relating to appealing your health insurance claim:

Who We Are: At Johnstone Trial Law, we represent health insurance policyholders and other policyholders who have disputes relating to insurance. We also represent people in car wrecks, boating accidents, and other personal injury matters. We believe in putting our clients first and representing them honestly, with passion, and with hard work.

Disclaimer: No representation is made that the quality of the legal services to be performed is greater than the quality of legal services to be performed by other lawyers.

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