What if my claim is denied?


Editorial team Published on

When an insurance or formal claim is denied, the insurer or agency refuses to pay for the requested service, medical treatment, or loss, but you have the right to find out why and fight the decision.

What Happens Next

  • Written Explanation: The company must send a formal denial letter explaining the exact reason for the rejection (such as missing paperwork, coding errors, or lack of medical necessity).
  • Financial Responsibility: If the denial stands and is not overturned, you may be held responsible for paying the costs out of pocket, or a healthcare provider may bill you directly.
  • Deadlines Begin: A strict timeline starts the day you receive the notice, giving you a limited window to take action.

Steps You Can Take

  • Check for Errors: Call the company or your provider to look for simple administrative, billing, or paperwork mistakes that can be easily fixed and resubmitted.
  • File an Internal Appeal: Submit a formal request and extra proof—such as medical records or a doctor's letter—asking the insurance company to review its choice. You can learn more about your rights on the HealthCare.gov Appeals Page.
  • Request an External Review: If your internal appeal fails, you can ask a neutral third party or independent organization to look at the case.
  • Contact State Regulators: If you believe the company acted unfairly or in bad faith, reach out to your state's insurance department for help. For further guidance, read these Tips for Handling Insurance Claim Denials from APA Services.