How to Dispute an Insurance Claim Denial

Few things are more frustrating than depending on insurance recovery and having your claim denied.  But, you should know that there are ways to dispute any claim denial. These general rules apply to any kind of insurance, health or medical, and property and casualty.

Reasons You May Have Been Denied

• Health insurance –
  • Out of network provider
  • Bad submission by the provider
  • The plan needs more information
  • The procedure wasn’t considered medically necessary
  • They made a mistake
• Property & Casualty
  • Non-covered peril
  • Not enough coverage
  • Waited too long
  • Exclusion clauses
  • False statement

Steps to Appealing a Denial

• First, find out why your claim was denied. Some, like typos, are easily fixed. Others, like medical necessity or the company saying you made a false statement, can be challenging.
• Check your policy – was the denial within the precise terms of the policy? For example, flood damage is almost always excluded from homeowners insurance.
• Are there appeal deadlines in the policy? Make sure you meet them.  Always start the process quickly.
• Argue your case. If you think the denial was wrong, you need to convince the company that it is. If you can cite specific policy provisions in doing so, that’s even better.
• Write it up in an appeal letter – not too long and not too emotional. Try to sound professional – it will get a lot more attention.
• Follow up if you don’t hear back soon. Things pile up on people’s desks.

Get Help with Your Claim Dispute

Contact an insurance claims denial attorney today.  Knowledgeable, experienced counsel won’t be intimidated by insurance company lawyers whose job is to keep their employer from paying one dollar more than necessary.

1. What is a bad faith insurance claim denial?

If your insurance company unreasonably or unfairly denies your claim in a manner that violates the duty of good faith that the company owes you, it can be held accountable for significant money damages.

2. Are there any exceptions to the out-of-network claim denial?

Yes. There is a procedure called a coverage gap exception, where you can request coverage for an out-of-network provider by establishing that there is no in-network provider who offers that service.  You should request a gap exception prior to making a claim, not as a defense to a denial.

3. How long should an appeal of a denial take?

In health insurance, the appeal has to be completed within 30 days if you haven’t had the care yet and within 60 if you have.