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The right to appeal a denied health insurance claim

On Behalf of | Jul 12, 2023 | Delayed And Denied Insurance Claims | 0 comments

Dealing with insurance can be incredibly frustrating. You may have paid your insurance premiums for years only to find that when you need to pay for a medical procedure or prescription, your insurance denies your claim.

What can you do in this situation? You’re just one person, and you must go up against a powerful insurance company.

Fortunately, federal law protects your rights.

The right to appeal

You have the right to appeal an insurance company’s decision about your coverage. The Affordable Care Act strengthened this right.

When denying your claim, the insurance company must inform you of your right to appeal and give you some basic information about how to do so, including deadlines and submission requirements.

Reasons to deny a claim

When denying your claim or request for coverage, your insurer must provide you with the specific reason it denied your claim.

Most denials fit into one of the following categories:

  • Not medically necessary or appropriate: Insurers may deny coverage for treatments they consider unnecessary or inappropriate under the specific circumstances.
  • Unproven: Insurers sometimes deny claims for treatments that they believe are experimental or have been medically unproven as effective.
  • Lack of eligibility: The terms of your health plan may mention certain types of treatments that the insurance company will not cover.
  • Lateness: Insurers may deny a claim if they determine it was filed too late.

If you are denied coverage for one of these reasons, the appeals process ensures that the insurance company doesn’t necessarily get the last word.

Terms of the contract

Your insurance policy is a type of contract, and both you and the insurance company are bound by its terms. This means your appeal will likely involve arguing over whether the insurance company’s stated reasons for denying your claim meets the terms of the contract.

For example, if the insurance company tells you it has denied your claim because it was not filed in a timely manner, you can look through your policy to see if it has language about specific deadlines, and whether your claim was in fact too late. You may be able to successfully argue that your claim fell within acceptable time limits.

It’s important to remember that insurance companies have a financial incentive to pay out as little as they can. They are highly skilled at digging through the terms of health policies in order to find loopholes and exceptions that allow them to deny coverage. It’s hard for the average person to compete with insurance companies when it comes to this kind of work.

Fortunately, you don’t have to take on this burden all alone. It’s wise to seek out experienced help.