Insurance companies deny claims more often than most people realize — and most denials can be successfully overturned on appeal. Here's how to fight back.
Step 1: Understand Why
Request the denial in writing with the specific reason. Common reasons: "not medically necessary," "out of network," "pre-existing condition," "exceeds policy limits," or "missing documentation."
Step 2: Gather Evidence
- Get a letter from your doctor explaining medical necessity
- Document everything with dates, names, and reference numbers
- Request your complete claims file from the insurer
- Research your policy language — denials often misapply terms
Step 3: File Internal Appeal
You have 180 days to appeal (ACA requirement). Write a detailed letter addressing each denial reason with supporting evidence. Include all medical records and doctor letters. Send via certified mail.
Step 4: External Review
If internal appeal fails, request external review by an independent third party — this is your legal right under the ACA. External reviewers overturn insurance denials 40-60% of the time.
Step 5: Escalate
File complaints with your state insurance commissioner. Consider hiring a patient advocate ($100-$200/hour) or attorney for large claims.
