How to Dispute an Insurance Claim Denial

Three Parts:Preparing to Dispute the ClaimDisputing a Health Insurance DenialDisputing an Automobile Insurance Denial

Most people have some form of insurance, with health insurance and automobile insurance being the most popular. If you submit a claim to an insurance company, then you probably expect the insurance company to pay out the claim. If they don’t, then you need to know how to dispute the denial.

Part 1
Preparing to Dispute the Claim

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    Understand why insurers typically deny claims. Claims can be denied for a variety of reasons. Not every denial will apply to each form of insurance. However, common reasons for denials include:
    • You were at fault. If you have automobile insurance, then the insurer will not pay a claim if it finds that you could have avoided the accident or it was caused by your actions.[1]
    • The claim is not covered by the policy. Insurance policies are contracts that define each party’s obligations. The insurer agrees to cover only certain claims as outlined in the contract.
    • The coverage has lapsed. If an accident occurs during a gap in coverage, your insurer will likely deny your claim. A lapse in coverage may occur if you did not pay your insurance premium.
    • A claim was submitted wrong. Sometimes, your doctor may use the wrong code for a procedure, causing the insurance company to believe that the procedure falls outside your coverage.[2]
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    Read your denial letter. The first thing you should do is read the letter from your insurer stating the reasons why your claim was denied. The insurer should also state in the letter what procedures you can follow to appeal its decision.[3]
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    Find your policy. You will also need to reread your policy to confirm that the insurer has grounds for denying the claim. Pay particular attention to the description of what claims the policy will cover.
    • Health insurers will also provide a document called “Evidence of Coverage” if you ask. They should also provide the guidelines that they use to determine what is medically necessary.[4] Get this information and read it.
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    Gather evidence to support your claim. The kind of evidence you need depends on your facts and circumstances. Pay particular attention to why you were denied coverage. Then think of any evidence you can get that disproves the reason for the denial.
    • For example, your medical insurer may refuse to pay for treatment that it considers unnecessary or ineffective. You could try to rebut this reason by getting a letter from your doctor explaining why the treatment is necessary and effective.

Part 2
Disputing a Health Insurance Denial

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    Contact a Consumer Assistance Program. If at any time you need help navigating the appeals process, then you should contact your state’s Consumer Assistance Program. Thirteen states have a CAP in operation. To find assistance, visit the Centers for Medicare and Medicaid Services website for an interactive map.
    • If your state does not have a CAP, you can reach out to your state insurance regulator for assistance. To find your state’s regulatory commission, visit this map from the National Association of Insurance Commissioners.
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    File an internal appeal. With health insurance, the Affordable Care Act has mandated an appeals process. The process has two parts: first you file an internal appeal with the insurer. Under the Affordable Care Act, if you want to lodge an internal appeal, you must undertake three steps:[5]
    • complete all forms required by the health insurer or write the insurer with your name, claim number, and health insurance ID number
    • submit additional information that you want considered
    • submit all information within 180 days of receiving your denial notice
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    Wait for a decision. An internal appeal must be completed within 30 days if the appeal is for a service you have yet to receive and within 60 days if for a service you’ve already received. Your insurer must send you a written decision.[6]
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    Ask for an external review. The second step of the appeals process is to ask for an external review if the internal review results in a denial. The denial letter issued after your internal appeal should state how you can ask for an external review.[7] You may request the review yourself or have a representative (such as a doctor) request it on your behalf.[8]
    • You must request an external review within 60 days of receiving the insurer’s final decision. Your insurer may allow more time—the letter should state how much time you have.[9]
    • If you have an urgent medical situation, you can request an external review even if you have not yet completed the internal appeal process. If the timeline for filing an internal appeal would jeopardize your life, then you should request an expedited external review.[10]
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    Identify the types of denials that can be reviewed externally. An external review by a third party is available for the following denials:[11]
    • any denial that involves medical judgment where you disagree with the insurer
    • any denial that involves a determination that a treatment is investigational or experimental
    • cancellation of coverage based on the claim that you gave false or incomplete information
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    Pay for the external review. Each state has the option of creating its own external review process that meets (or sometimes exceeds) the ACA standards. If your state did not create an external review process, then you will use the process overseen by the federal government’s Department of Health and Human Services (HHS). The federal service is free of charge.[12]
    • A state external review program cannot charge more than $25 per review.[13]
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    Receive a decision. An external review decision will be rendered within 60 days after the request is received.[14]
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    Consider bringing a lawsuit. If the external review is not favorable, then you should meet with an attorney to discuss bringing a lawsuit for “bad faith.” Gather all of your documentation and schedule a consultation. Examples of an insurer’s “bad faith” include:[15]
    • failure to respond in a timely fashion
    • declining a claim
    • failure to investigate
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    Find a lawyer. To schedule your consultation, try to find an experienced attorney who has handled insurance disputes. Typically, you can find a lawyer through your state’s bar association program, which should run a referral service.
    • If money is tight, you might try to find a legal aid organization in your area. Legal aid organizations provide low-cost or free legal services to people with low incomes. To find a legal aid organization in your area, use the Legal Services Corporation’s locator.

Part 3
Disputing an Automobile Insurance Denial

  1. Image titled Have a Good Job Interview Step 9
    Ask the insurer to reconsider. If your insurance claim was denied, you should talk to your insurer to talk about the reason for the denial. If you believe that there is additional information that would help them to reassess your claim, then provide the insurance adjuster with the information and resubmit the claim.[16]
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    Preserve all communications. To successfully resolve your insurance dispute, you need documentation of every communication you have with the insurance company. Accordingly, it is ideal if you can communicate in writing or by email.
    • Making phone calls is often more convenient, as each party can ask and answer questions, potentially resolving the dispute easier. If you want to communicate by phone, you should take detailed notes of the conversation. Write down the day, time, and name of the person you talked to. Then summarize the conversation.
    • For important phone calls, you can follow up with a letter summarizing your interpretation of the conversation.
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    Remain calm. As you go back and forth with the insurer, it is important to remain calm at all times. Always be unemotional and professional.[17]
    • As the appeals process continues, you can gradually increase your assertiveness.[18] Still remain professional, but don’t automatically accept an initial offer to appease you.
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    Hire an independent appraiser. If you are not happy with the insurer’s resolution of your dispute, then you can think about hiring an independent appraiser. This option is particularly helpful when your car has been damaged but the insurer doesn’t want to pay to fully fix the car. If the appraiser agrees with you that the insurer is underestimating the cost, then you can send the report to the insurer.[19]
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    Consider alternate dispute resolution (ADR). ADR typically encompasses mediation and arbitration. These are resolution techniques that can keep you out of court and lower the cost of the dispute.
    • With mediation, you and the insurance company would meet with a third-party neutral to discuss the dispute. The mediator’s recommendations are non-binding, but the mediator can suggest solutions that are agreeable to both parties.[20]
    • With arbitration, both sides present a case to a third-party arbitrator. Arbitration differs from mediation in one key way: parties agree to abide by the arbitrator’s decision.[21]
    • ADR is rarely free. So you should always weigh the expense of arbitrators, mediators, and attorneys against the value of your claim. If the amount in dispute is significant, then you might want to consider it.
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    Contact your state insurance regulator. If your insurer denies your claim again, then you may want to contact your state insurance commissioner, which should have created a process for receiving, reviewing, and investigating consumer complaints. If you feel that your claim was denied for no good reason, then you should contact them.[22]
    • Each state’s commission is different, and not all regulators will investigate all denials. To find out your state’s process, visit this map from the National Association of Insurance Commissioners.
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    Hire a lawyer to sue. You can sue the insurance company for a bad faith denial of coverage.[23] These lawsuits can be complicated, but you will want to find a qualified personal injury attorney who has experience suing insurance companies.
    • To find an experienced attorney, contact your state’s bar association. You can find your state or local bar association by using this map from the American Bar Association.
    • For an overview of a “bad faith” lawsuit, see How to Sue an Insurance Company After an Auto Accident.


  • If you want to appeal a Medicare denial, then you will need to go through the Medicare appeals process. You can access that information from the website. Click on “Claims & Appeals.”[24]

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