How to Appeal an Insurance Claim Denial

When you have an accident or an injury, you count on your insurance company to help you and provide coverage of your claim. However, in many cases, you will receive a letter that your claim has been denied. What that happens, you will need to know how to review the denial and prepare an effective appeal. The two major areas for insurance claims are medical appeals and automobile claims. These each have their own procedures and strategies.

Part 1

Part 1 of 3:

Preparing a General Appeal

1
Review the denial letter from your insurer carefully. The letter that you receive from your insurer should provide information about filing an appeal of the decision. It should also explain the reasons for denying your claim. Read it carefully and understand the basis for the denial.^{[1]XResearch source} Some of the common grounds for denying insurance claims are:
- You caused the accident. This will apply primarily to automobile claims. If the insurer believe that you were at fault for the damage to your car, your claim will probably be denied. Alcohol use is likely to fall into this category.
- Your policy does not cover the claim. Your insurance policy is a contract that defines what kind of claims will or will not be paid. If you are claiming something that is not allowed in the contract, then your claim will be denied.
- Your policy has expired. An insurance policy usually lasts for a particular period of time, generally one year. At the end of the policy, you will need to renew it. If you do not, then you do not have insurance coverage. This may also occur if you fail to pay your premiums on time.
- You failed to comply with proper filing procedures. This may occur from a claim you filed, or it could come from your doctor's office. Sometimes a simple clerical error could result in a denied claim.
2
Contact the insurer directly. Your letter should provide a customer service telephone number. Call the insurer and ask for an explanation about the denial of your claim. Quite often, this direct conversation may lead to an understanding of a simple problem, and you may resolve the dispute quickly. If not, you may at least gather information that you can use to file your appeal.^{[2]XResearch source}
- When you call the insurance company, keep the conversation businesslike and unemotional. Simply say, “I received a letter that my claim from October 20 was denied. Can you explain to me why this claim was denied?”
- Take good notes of the conversation. Record the name of the person you speak with, and get a reference number or case number for your phone call.
- Ask the representative for a document called “Evidence of Coverage.” This is a statement that details what your plan covers and what the company will pay.
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Reviewing the exact language of your policy will help you either verify that the denial was correct or find support for an appeal. You will especially want to study the section of your policy that defines allowable claims and coverage.^{[3]XResearch source}
4
Prepare an appeal packet. To support your appeal, you need to provide some evidence. Take time to review the denial, and then gather information that will support your claim. Some examples of helpful materials include:^{[4]XResearch source}
- A letter of support from an expert. If you are appealing a medical claim, this will be from your doctor. If it is an automobile claim, you may have a letter from a mechanic or appraiser about the work that your car requires.
- Results of any testing that was performed.
- Articles or journals that will describe your medical condition and support your doctor's conclusions.
- Your own narrative of the facts of the incident and the basis for the claim.
5
Craft a strong appeal letter. Whether you are appealing a medical claim or an automobile claim, you will need to submit a strong letter that explains your claim. A strong appeal should do the following:^{[5]XResearch source}
- Begin with a clear statement like, "I am writing to appeal your denial of my insurance claim. I received your letter dated ____, and I am writing now to provide additional information to support my claim."
- Describe your problem. For a medical claim, you will describe your medical condition and how it has affected your life. For an auto claim, explain the incident as clearly as possible and the reasons that you are not at fault.
- Explain your rationale for believing the claim should be covered. Refer to sections of your policy, if possible. You might make some statements like, "In section ___ of my insurance policy, it says that you cover hospital stays when deemed necessary by the primary care physician. In this case, my primary care physician made the decision that my hospital stay was necessary."
- Explain why paying your claim makes good financial sense. If possible, explain that this one payment may prevent future injury, illness or damage that would result in higher eventual costs.
- Provide contact data for both you and your doctor (for medical claims). One of the later paragraphs of your letter should say, "If you have any additional questions or need further information, you may contact me at _____ or my doctor at _______."
6
Submit your claim. Put together your appeal letter with whatever evidence you have gathered. Make a copy to save for your own reference, or in case the letter does not get delivered for any reason. Follow any instructions from your insurer about where to send the appeal.^{[6]XResearch source}
- It is a good idea to send your appeal package by certified mail, with a request for a return receipt. This will ensure that the material arrives to the right place. The receipt will give you evidence of delivery in case of any dispute.
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Part 2

Part 2 of 3:

Appealing an Auto Insurance Claim Denial

1
Resolve the claim with the insurance company directly, if possible. When you receive notice that your automobile claim has been denied, or that the company is offering a payment less than satisfactory, you should first call your insurance company. The company often has some flexibility in what it pays, and the first letter is often like the first offer in a negotiation. If you express your dissatisfaction firmly, especially if you have any additional information to support your claim, you may be able to get the company to increase its payment.^{[7]XResearch source}
- Take good notes of your conversation. Get the name of the person you speak with, and ask for a confirmation number or case number for the conversation.
- Follow up in writing. Even if nothing is finally resolved, a letter will document the discussion. In your letter, you can say something like, “Thank you for speaking with me today about my claim from October 14, 2016. I understand that my claim was initially denied because ______. As I told you, I will gather more information and submit it to you shortly.”
2
Maintain a businesslike demeanor. Although this may mean a great deal of money to you, you need to remain calm when speaking with the company. Be professional and address the issue directly. Focus on the problem itself and do not get personal or argumentative.^{[8]XResearch source}
- If you find yourself become angry or agitated, you may need to stop the conversation. Simply say, “I'm sorry, but I need to go. I will contact you another time so we can continue this discussion.”
Very often, the allowance or denial of a claim will rest on the appraiser's opinion of the damage to your vehicle. The insurer's appraiser may have an incentive in undervaluing the work that needs to be done. If you get an independent opinion from another appraiser, you can send that report to your insurance company to appeal its decision.^{[9]XResearch source}
4
Participate in alternative dispute resolution (ADR). The general phrase alternative dispute resolution includes both mediation and arbitration. These are two options that use the services of an outside professional to help you resolve your dispute without going to court.^{[10]XResearch source}
- Mediation involves the two parties, you and a representative of your insurance company, and an independent third party who serves as the mediator. You each will discuss your position with the mediator, who is then trained to help you both find a common position in the middle. A mediator is not generally about “right” and “wrong” but is more about finding agreement.
- Arbitration is a sort of preliminary trial. The two parties select a third-party arbitrator, who then hears each side's case. Depending on the value of your claim or the complexity of the issue, arbitration can be a very informal matter or can have all the formalities of a full trial. At the end of the proceeding, the arbitrator will give his or her decision. Arbitration can be either binding, which means that you both agree before the process begins that you will abide by the arbitrator's decision, or non-binding, which allows you to hear the decision but not accept it.
5
Proceed with a lawsuit in court. If the insurance company still refuses to allow your claim, and you believe that the claim is valid, then you may file a complaint in court. The primary basis for an insurance claim to go to court is that the company is denying your claim in “bad faith.” This basically means that you have a contract--your insurance policy-- and the company is refusing to follow it without good cause.^{[11]XResearch source}
- Filing a case in court can become more complicated and more costly. You will only take this step if the amount of your claim is substantial.
- If you have not yet done so, you should consult with an attorney. To find an experienced attorney to help with your insurance case, contact your local bar association. They generally keep lists of attorneys for referral, arranged by practice field.
- When you meet with prospective attorneys, find out about their experience with automobile insurance cases. Ask, “How many cases like this have you filed? What has been your history of success with cases like mine?”
- For an overview of a “bad faith” lawsuit, see How to Sue an Insurance Company After an Auto Accident.
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Part 3

Part 3 of 3:

Appealing the Denial of a Health Insurance Claim

1
Get help from a Consumer Assistance Program. If you need help appealing a health insurance denial, you can seek help from you state's Consumer Assistance Program (CAP). As of the writing of this article, thirty states, along with the District of Columbia, Northern Mariana Islands and the Virgin Islands, have a CAP in operation. To find out what resources exist in your state, and to find out how to contact the CAP, visit the Centers for Medicare and Medicaid Services website at https://www.cms.gov/CCIIO/Resources/Consumer-Assistance-Grants/. You will find an interactive map with the information you need and links to each state's contacts.^{[12]XResearch source}
- CAP centers exist to provide help to consumers about their insurance. By contacting your state's CAP, you can reach someone who can help you review your denial and understand the steps to file an appeal. You can also get help finding insurance coverage or understanding your own eligibility for coverage.^{[13]XResearch source}
2
Seek assistance from your state's insurance regulator. As another source of support, you can contact your state's insurance regulator. You can find contact information for every state in the U.S. at http://www.naic.org/state_web_map.htm. From that map, you can select your state and you will be redirected to the address and contact information for your state's insurance regulator.^{[14]XTrustworthy SourceNational Association of Insurance CommissionersRegulatory support organization responsible for setting standards for insurance commissions in the United States.Go to source}
- Insurance regulators exist to help consumers with complaints about insurers and to help them understand insurance companies' decisions.
3
Begin by requesting an internal appeal. Since the passage of the federal Affordable Care Act, insurance companies in every state must provide a uniform appeals process. The first stage of this process is to file an internal appeal with the insurance company. To initiate an internal appeal, you need to do the following:^{[15]XResearch source}
- Notify your health insurance company that you wish to submit an internal appeal, and complete any paperwork they provide. Alternatively, you can write directly to your insurance company with your name, claim number, and health insurance identification number.
- Submit any additional documentation that you have that will support your claim. Providing a letter of support from your physician would be helpful. Ask your physician to explain the services provided and the fact that they were “medically necessary.”
- Submit your appeal within 180 days of receiving notice of the denial.
4
Review the decision from your insurer. Your insurer must respond to your internal review request within 30 days if the claim was for a service that you have not received yet. If the claim is for a service that you have already received, then you must receive your response within 60 days.^{[16]XResearch source}
- The insurance company must respond to you in writing. If the decision is to deny your claim again, the company must provide you with information about moving forward with an external review.
5
Seek an external review. Within 60 days after receiving the denial of your internal review, you must request your external review. The letter that you receive denying your claim will include the procedures for moving on to this final stage. The procedures differ from state to state and among insurance agencies. Read the notice carefully and follow the procedures precisely.^{[17]XResearch source}
- Some insurance companies may allow longer than 60 days for requesting an external review. The letter that you receive with your denial should set the deadline for you.
- You may file your own request for external review, or you may have someone request it on your behalf. This could be your doctor or an attorney.
- If your claim is for care related to an urgent medical condition, you may request your external review in one step at the same time that you request your internal review.
6
Know what you can appeal to the external review level. You are limited in the types of claims that are allowed to go from the internal review to the external review. The following are the types of claims for which you may request external review:^{[18]XResearch source}
- claims for which your doctor disagrees with the insurance plan on a matter of medical judgment
- claims based on treatment that is experimental or investigational
- decisions about cancelling your coverage because the insurer alleges that you gave false or incomplete information when you applied for coverage
By law, the final decision on your external review must be provided to you within 60 days. If the ultimate decision is to deny your claim again, the insurer must provide you with a written statement of its reasons.^{[19]XResearch source}
8
Consider bringing a lawsuit. If you are still not satisfied with the outcome of your claim following the external review, you may wish to consult with an attorney and take the matter to court. A legal claim in court is generally going to be based on an argument that the company acted in “bad faith.” To make this argument, you usually will need to show one or more of the following:^{[20]XResearch source}
- The company failed to respond to your claim in a timely manner.
- The company acted inappropriately in denying your claim or by refusing to settle.
- The company failed to investigate the facts surrounding your claim adequately.
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