Appealing a Health Insurance Denial

Reading time: 4 minutes

It’s crucial to ensure you and your loved ones are safe and healthy during the Coronavirus/Covid-19 pandemic, especially as more states lift stay-at-home orders and businesses gradually reopen. You may be following recommended precautions to protect yourself from illness, including washing your hands frequently, social distancing and wearing a mask when you leave home.

At the same time, you may be concerned about how you would afford the cost of treatment should you or a loved one get sick. Dealing with an illness or injury is difficult enough without the financial burden of paying for your care, especially if your health insurance claim is rejected. An insurance company may deny payment for medical care for a variety of reasons, including a determination that the treatment your doctor has recommended isn’t medically necessary.

But you don’t have to accept a denial as the final answer. If your insurance claim is rejected, you can file an appeal — or several, if necessary — to persuade your insurance company to cover the treatment.

The first step, though, is to try to avoid a denial in the first place by understanding your health insurance plan. Review the limits and guidelines of your particular policy and follow them to the best of your ability. If you are required to secure a referral from your primary care provider before seeing a specialist, do so to avoid a denial.

While some denials are clear-cut — for example, if an HMO requires you to remain within its network and you go to a specialist that is out of network — others are more subjective. An insurance company might deny preauthorization for a procedure that it considers a nonstandard treatment. It might reject a promising cancer therapy that your doctor has recommended because the treatment is considered experimental, or it might refuse to pay for medical care that you’ve already received, deeming that treatment not medically necessary and putting you on the hook for payment.

Read the fine print to make sure you understand what your particular policy covers.

What should I do if I lost my employer-provided health insurance during the Covid-19 pandemic?

Importantly, you first need to remember that you aren’t alone in facing this sort of financial challenge. A recent analysis from the Kaiser Family Foundation found that an estimated 27 million people have recently lost their health coverage.

Fortunately, the vast majority of those who find themselves without insurance can remain covered by switching to a spouse’s plan or are eligible for subsidized health insurance from other sources.

If you’ve lost your insurance coverage due to unemployment, you are likely eligible for what’s called a “qualifying life event.” You can sign up for a new plan at healthcare.gov or visit your state’s insurance exchange to explore your options. It’s crucial that you apply within 60 days of losing your coverage — so depending on when you lost your job, you may need to act quickly.

Understand the health insurance appeal process

If a medical claim is denied and one or more internal appeals to the insurance company are unsuccessful, consumers have the right to request an external review that meets state and federal requirements. It’s a lot of effort but may be worth the hassle. In fact, consumers who appeal outside of their private insurance companies win their cases an average of 45 percent of the time, according to the Kaiser Family Foundation.

When submitting your appeal, keep in mind that the best defense is a good offense. As you put together an appeal packet, include as much supporting detail and as many relevant documents as possible. Also, keep a close eye on any deadlines specified by your insurance company.

Your policy will outline the specific timeline and process for contesting a denied claim. If you fail to appeal in a timely manner, however, you have no recourse. There are three levels of appeals, so even if your first attempt does not go in your favor, continue the process, paying close attention to why the appeal was denied and the required time frame for additional appeals.