When the Claims Denial Arrives: Tips for Appealing the Insurance Company’s Decision

Insurance by definition exists to provide us assurance that when the unthinkable happens, we have a safety net to fall back on. But what happens when your insurance company isn’t there for you when you need it most? What happens when your claim gets denied? Regardless of whether you are submitting a regular health insurance claim, a short- or long-term disability claim, or an ERISA claim, denial is a reality that too many people have to deal with. And, without fail, that claims denial shows up at the precise moment that you are least equipped to deal with it.

Of course, these different types of insurance—health, disability and ERISA—kick in to provide you coverage in different circumstances. Health care coverage, as most of us are aware, is simply to provide insurance payment for medical treatment that you need. Disability coverage may be something you personally purchased, may be supplied by your employer, or may be part of a government program. Regardless of its source, the idea behind disability insurance is to provide you with income in the event that you suffer an injury or illness that prevents you from working, either temporarily or permanently. And ERISA is a law that governs employer-provided insurance plans, creating certain protections for employees.

Whatever the source of the insurance, when the claims denial shows up, patients are often left wondering how they are going to pay for expensive medical procedures or how they will make ends meet until they can get back to work. But the denial is rarely the end point for these situations: there is a way for consumers to fight back through a claims denial appeal process. In this appeal, you, the consumer, have the opportunity to present the insurance company with additional information and request that they re-assess their initial response.

Here are some tips for navigating the appeals process:

Assess whether you need the advice of an attorney. This, of course, is a very personal decision and one that should not be taken lightly. Consider how comfortable you are in understanding the terms of your policy and the situation generally. Another factor to consider is the expense involved—is it a few hundred dollars for a single procedure or several thousand for a medical issue that requires ongoing treatment?

Understand the denial. This starts with information about the denial—you can’t formulate an appeal without knowledge of what you are appealing. Upon request, the insurance provider should send you a letter detailing why the claim was denied. Some common reasons might be that the procedure wasn’t medically necessary or required pre-authorization from the insurance provider. Maybe you were at an out-of-network healthcare provider. Or the insurance company may consider your condition to be pre-existing.

Gather information to support your position. Each of these reasons for denial will require its own specific response and you will need to gather information that supports your argument that your claim should be covered. This means carefully consulting with your physicians for an explanation about why you need a specific treatment or an explanation on the nature of your medical condition. You can even request that your doctor submit a letter on your behalf.

Formulate the appeal. After you understand why your claim was denied, and have gathered all the information to support your position, it’s time to write and submit the appeal. Your appeal letter should clearly identify your claim, the reason for denial, and your reason for appealing. Include supporting information from your doctor, including helpful portions from your medical records.

Be persistent. When it comes to appealing a denial, persistence—and sticking up for your rights—can pay off. Sometimes denials are practically automatic for insurance companies; even just questioning them a little bit can result in a reversal of the denial. Other times, lots of phone calls, letters and information exchanges will be necessary.