Health Insurance Denied You? How to Fight Back

A health insurance denial can feel like a closed door: the treatment your doctor ordered, refused by a company you've never met. But a denial is the start of a process, not the end of it. For people with chronic and rare illnesses — who file more claims, try more treatments, and hit more walls — knowing how to appeal is a survival skill.

Start with the denial letter

Don't throw the letter away or assume it's final. Read it carefully. By law, denial notices for most plans must tell you the reason the claim was denied and your right to appeal. The Explanation of Benefits (EOB) is not a bill — it only describes what the insurer decided — so read what it actually says rather than what you fear it means.

Identify the denial reason. The most common ones for chronically ill patients are "not medically necessary," missing prior authorization, out-of-network charges, and exclusions for experimental treatments. The reason determines what evidence you need. A medical-necessity denial needs clinical evidence; an authorization denial may just need paperwork.

While you're at it, figure out what kind of plan you have. Coverage through an employer is often governed by federal ERISA rules; individual plans and most state-regulated plans fall under Affordable Care Act (ACA) appeal rules. Medicare, Medicaid, and VA coverage each have their own separate appeal systems. If you're unsure, your HR department or the number on the back of your insurance card can tell you.

File an internal appeal — and do it in writing

The first step is an internal appeal: you ask the insurer itself to reconsider. Here is the step-by-step:

• Act within 180 days. For most plans, you must file your internal appeal within 180 days of the denial. Missing this deadline can permanently end your right to challenge it — mark your calendar the day the letter arrives.
• Request the appeal form or instructions. Most insurers have a specific form or process described in your plan's Summary Plan Description or on the denial letter. Use it, and keep a copy of everything you send.
• Build your case. Gather the denial letter or EOB, any prior-authorization correspondence, your medical records, and a letter of medical necessity from your treating doctor. Ask the doctor to explain, in clinical terms, why the treatment is appropriate for your specific condition and why alternatives were rejected.
• State the facts plainly. Write a dated letter with your name, policy number, claim number, the service denied, and the denial reason you're disputing. Attach your evidence. Send it by a trackable method.
• Request expedited review if it's urgent. If the denial involves ongoing or urgent care, say so explicitly and ask for expedited handling — your doctor may need to certify the urgency. Insurers must decide urgent appeals within 72 hours.

Once filed, the clock starts on the insurer. For denials of care you haven't yet received, the plan generally must decide within 30 days; for services you already received, within 60 days. Track the deadline — and write down the date, time, and name of every person you speak with along the way.

If the internal appeal fails, request external review

This is the step too many patients skip. If your internal appeal is denied, you can ask for an independent external review: a third-party reviewer — not your insurer — examines the case and makes a decision. For most plans, you must request it within four months of the final internal denial notice.

External review matters because the reviewer is independent, and the decision is binding on the insurer. Standard external reviews are typically decided within about 45 days; expedited ones within about 72 hours. It's usually free, it doesn't require a lawyer, and it frequently overturns medical-necessity denials that the insurer refused to budge on. Depending on your plan and state, the review goes through your state Department of Insurance, a state-contracted independent review organization, or the federal external review process.

Keep appealing through every internal level your plan offers before this point — for some plans, exhausting internal appeals is a prerequisite for external review.

Know the special rules for your situation

A few common scenarios deserve their own notes:

• ERISA employer plans. Self-funded employer plans don't always have state-run external review, but many have adopted it. A lawsuit after a denial generally recovers the benefit itself and possibly attorney's fees — know this before litigating.
• Medicare and Medicaid. These have entirely separate, multi-level appeal paths with their own deadlines. Don't use the private-insurance playbook for a Medicare denial; follow the instructions on your Medicare Summary Notice.
• Surprise out-of-network bills. Emergency care and some out-of-network charges carry special protections under the No Surprises Act. If an emergency-room bill looks wrong, that may be a separate dispute, not a standard appeal.

You don't have to do this alone

Appealing is paperwork-heavy and exhausting — exactly the kind of task that's hardest when you're sick. Help exists:

• Consumer assistance programs. Many states have free programs that help residents file appeals and request external review. Your denial notice or state Department of Insurance website can point you to yours.
• Your HR department. For employer plans, HR or a benefits navigator can often cut through the insurer's process faster than you can alone.
• Patient advocacy organizations. Many condition-specific nonprofits maintain guides and templates for appealing denials common to their diagnosis.
• Professional help. If the claim is large or the case is complex, a patient advocate or health-insurance attorney can take it on. Some work on contingency for large claims.

The throughline of all of this: denials are a routine part of how insurers operate, and appeals are a routine part of how patients push back. A denied claim is a decision, and decisions can be challenged. Keep your records, watch your deadlines, and don't let a form letter have the last word on your care.