How to Appeal a Health Insurance Claim Denial

If you recently had a health insurance claim denied, then one of the things that you might want to do as quickly as possible is filing an appeal. Insurance companies may deny claims that are legitimate from time to time. This may be an accident, or it may be a way to save them money. In these cases, filing an appeal and doing the work that goes into it can give your claim a much better chance of getting approved. If you think that your claim was denied unjustly, then let’s go through the process of what you need to do to file an appeal and possibly get it approved after all.

Step One: Research Your Policy

The first thing that you’re going to have to do is research and policy carefully and find out whether or not the insurance company was correct in denying your claims. If it states in your policy that whatever medical procedure was performed was not covered, then you really have no basis for appeal. You may still appeal, but you are likely going to get denied again. If you can find no reason for them to have denied the claim in your insurance policy, then you have a much stronger basis for which to file an appeal. Insurance policies are dense and difficult to read by nature, so you may need someone’s help.

Step Two: Make Your Argument

The next step in the process is to make your argument. Writing out an argument for why the procedure or expense should not have been denied. Use specific examples if you can find them from within your insurance policy, and you may even want to look up legal precedents to find out if other people filed appeals or lawsuits over the same sort of procedure and had their claims paid. It is unlikely that your insurance company will make public their record of appeals, but when it comes to lawsuits, these are public knowledge and can be researched.

Step Three: File Your Appeal

You’ll need to file your appeal next. You want to make sure that you pay attention to any filing limits or dates by which you need to file within your policy. You also need to find out what the process is. If they want you to file an appeal online, and you send in the paperwork, then they already have reason to deny your claim without even having to look at the reason it was denied in the first place. You want to make sure that you file your appeal on time in the exact same way that they specified in your paperwork. This will give your claim the best chance of getting a fair hearing.

Step Four: Contact an Attorney

If you can afford it, then you definitely should contact an attorney to handle your appeal. Insurance companies that have denied a claim that should’ve been approved are much more likely to comply with their policies when they know that there is an attorney representing the client filing the appeal. They know that if they deny the appeal without cause, then there is a good chance that the attorney will bring it to court and the court will decide in the client’s favor. This will cost them not only the amount of the claim but also expensive court costs and possibly punitive damages as well.

Step Five: Track Your Progress

You want to keep track of your progress as your appeal is filed. Check the online status regularly if it is available, or call the insurance company to find out what steeds your claim is in. If your appeal is going to be heard on a specific day, then make sure you call directly after the appeal is heard so that you can find out what the decision was on it. The faster you can get information about your appeal, the more quickly you will be able to react if something goes wrong.

Step Six: Talk to Your Agent

You might also want to talk to your agent. Many insurance agents can be client advocates against the company they work for if they think the client might be being treated unfairly.

The Bottom Line

The bottom line is that there may be things that you can do if your insurance claim is denied. If you can file an appeal or a lawsuit, there is a good chance that the claim will be approved if it was unfairly denied in the first place. Of course, it can get expensive to fight these sorts of battles, so hopefully, it was just a simple mistake on the part of the insurance company and an appeal does its job and gets you the money you need.