How Do You Appeal A Health Insurance Denial?

We rely on health insurance carriers to pay when a valid claim is made through our policy. Unfortunately, there are times when insurers deny a claim. When this happens, you need to know the steps to take to receive the coverage you deserve.

1. Determine why the health insurance claim was denied

Your insurance carrier will likely send an “explanation of benefits” form that indicates why a claim was denied. If you do not understand the explanation, call the insurer and ask them to explain it to you. In some cases, a simple error may have been made that could be straightened out over the phone. Make sure to get the name of the person you speak at the insurance carrier, as well as the date and reference number for the call.

2. Carefully review your health insurance policy

You need to thoroughly review your health insurance policy and understand what kind of coverage is offered and how copays are handled. In general, health insurance carriers include a summary of benefits online, but you should still read through the policy itself. In these situations, knowledge is power. Your health insurance policy is a contract between you and the insurer, and it is legally binding.

3. Learn about the deadlines for appealing your claim denial

Every health insurance carrier will have different appeals processes in place. Read your health plan and completely understand the process for filing an appeal, as well as any deadlines. Health insurance appeals can be incredibly complex, and missing a deadline could result in your appeal not even being heard.

4. Make your case to the insurer

You need to gather all documentation necessary to prove your case to the insurance carrier. You may discover that the mistake was made by a coding error at the doctor’s office or some other simple procedural matter. Gather all copies of your medical reports, medical tests, and letters from physicians that can explain your diagnosis and the reason you require coverage.

5. Write an appeal letter and go through the appeals process

When you draft your appeal letter to the insurance carrier, be sure to include your name, address, insurance identification number, and date of birth. List the date of services that were provided as well as the insurance claim number for those services.

Your first sentence for a claim denial appeal should include language stating that you are appealing the denial. The remainder of your letter should be a concise explanation of why your medical bills should be paid. You will close your appeal letter with a sentence of demanding payment. Keep all emotions out of the letter to the insurance carrier and attach all evidence you have to your appeal.

6. Go to the California Department of Insurance

If you have gone through the appeals process and are still unsatisfied with the results, you can take your case to the California Department of Insurance. File a complaint with the Department so they can conduct an investigation into the claim and the denial.

Can I sue my health insurance company for denying my claim?

If your health insurance carrier has denied your claim for invalid reasons, they may be guilty of bad faith insurance practices. In these cases, yes, you can sue your health insurance company for denying your claim. However, these cases are not easy to prove, and they will require assistance from an experienced San Diego bad faith health insurance attorney. You could recover compensation not only for the initial claim that led to the incident of bad faith but also for damages beyond the claim amount.