Insurance Claim Denial Appeals

Insurance Claim Denial Appeal Guide

Your insurance company denied your claim. Here is how to build an appeal that gets the decision overturned.

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Important: This guide is an informational resource prepared to the best of our knowledge and does not constitute legal advice for your specific situation. You remain responsible for all due diligence and ensuring that your filings conform to applicable court rules. For legal advice about your specific case, consult with a licensed attorney or your local court's self-help center.

Your claim was denied. The letter from the insurance company probably cites a policy exclusion, says the treatment was not medically necessary, or claims the damage is not covered. Every denial letter is required to tell you why and how to appeal. Under ERISA (29 U.S.C. section 1133), employer-sponsored health plans must give you at least one level of internal appeal. The Affordable Care Act (ACA section 2719) requires individual and group health plans to offer both internal and external review. For homeowner and auto claims, your state insurance commissioner handles complaints. The key in any insurance appeal is matching your evidence directly to the denial reason. This guide shows you what to gather and how to organize it.

Document Checklist

The denial itself

Denial letter
The written denial with the specific reason and the policy section cited -- this is your starting point
Explanation of benefits (EOB)
The EOB showing what was billed, what was paid, and what was denied
Appeal instructions
The appeal procedure included with the denial, including deadlines and where to send it
Claim number and policy number
Reference numbers you will need on every piece of correspondence

Your insurance policy

Declarations page
The summary page of your policy showing coverage types, limits, and deductibles
Relevant policy sections
The specific sections the insurer cited in the denial -- print and highlight them
Definition of covered services
The policy definitions of what is covered and any exclusions
Summary of benefits and coverage (SBC)
For health insurance, the plain-language summary your plan must provide

Supporting evidence

Medical records
Treatment notes, test results, and hospital records supporting medical necessity
Doctor's letter of medical necessity
A letter from your treating physician explaining why the treatment or procedure is needed
Repair estimates or damage reports
For property claims, independent estimates and contractor assessments
Photographs
Photos of damage, injuries, or conditions with dates and descriptions
Receipts and invoices
Itemized bills for services, repairs, or replacement costs
Independent medical opinion
A second doctor's opinion supporting the treatment your insurer denied

Correspondence with the insurer

Adjuster communications
Emails, letters, and notes from phone calls with your claims adjuster
Phone call log
Dates, times, names, and summaries of every call with the insurance company
Prior approval or pre-authorization
If the insurer pre-approved a treatment and then denied the claim, this is strong evidence
Written requests for information
Any letters asking the insurer for your complete claim file or policy documents

Escalation options

State insurance commissioner complaint form
Available on your state DOI website -- file after internal appeal is exhausted
External review request
For health claims under ACA, you can request an independent external review
Bad faith documentation
If the insurer is unreasonably delaying or denying, document the pattern for a potential bad faith claim
Attorney consultation notes
If the claim is large, a consultation with an insurance attorney may be worth the cost

Common Mistakes to Avoid

Don't make these errors

1Not reading the denial letter carefully -- the specific reason and policy section cited tell you exactly what evidence you need
2Missing the appeal deadline -- ERISA plans give you 180 days, but auto and homeowner deadlines can be as short as 60 days
3Accepting the adjuster's verbal explanation instead of getting everything in writing
4Failing to request your complete claim file -- under ERISA, you have the right to every document the insurer used in its decision
5Skipping internal appeal and going straight to a lawyer -- you often must exhaust internal appeals before external review or litigation

Organization Tips

Pro tips for success

Start your appeal packet with the denial letter and then the specific policy language that supports your claim
For health claims, get your doctor to write a letter addressing each reason in the denial point by point
Keep a phone log of every call: date, time, person you spoke with, what they said, and your reference number
For property claims, get at least two independent repair estimates to counter the insurer's estimate
Organize medical records in chronological order with the diagnosis and treatment plan highlighted
Create a cover letter for your appeal that lists every enclosed exhibit by number and briefly states what each one shows

Courtroom Preparation

Be prepared for your hearing

Internal appeals are usually paper-only -- your written submission and attached exhibits are your entire case
For external review of health claims, the independent reviewer only sees what is in your file -- include everything
If your appeal goes to a hearing, bring the denial letter, your policy, and all supporting evidence in labeled tabs
Know the difference between internal and external review -- internal is decided by the insurer, external by an independent third party
For ERISA claims, the appeal decision is often final for administrative purposes and determines what you can argue in court later
If you are attending a state insurance department mediation, bring copies of all correspondence and a one-page summary of your dispute
Stay factual and reference your policy language directly -- "Section 4.2 of my policy defines covered losses as..."

Frequently Asked Questions

What are my appeal rights under ERISA for employer-sponsored insurance?

Under ERISA (29 U.S.C. section 1133), your employer-sponsored plan must give you written notice of the denial with specific reasons, the plan provisions on which the denial is based, and a description of the appeal process. You get at least 180 days to file an appeal. The plan must review your appeal and decide within 30 days for pre-service claims or 60 days for post-service claims. You can submit new evidence and written comments with your appeal.

What is an external review and when can I request one?

Under ACA section 2719, if your internal appeal is denied, you can request an external review by an independent third party who is not employed by your insurance company. This applies to individual and group health plans for denials based on medical necessity, experimental treatment exclusions, or rescissions. The external reviewer's decision is binding on the insurer. You typically have 4 months after the internal appeal denial to request external review.

What is insurance bad faith?

Bad faith occurs when an insurer unreasonably denies, delays, or underpays a valid claim. Examples include denying a claim without investigating, ignoring evidence that supports your claim, or failing to explain the denial. Bad faith laws vary by state. If you suspect bad faith, document the timeline of your claim, save all communications, and note every delay or unexplained denial. Bad faith claims can result in damages beyond your policy limits.

How long do I have to appeal an insurance denial?

It depends on the type of insurance. ERISA health plans give you 180 days. ACA-compliant individual health plans must allow at least 180 days for internal appeals and 4 months for external review. Homeowner and auto insurance deadlines are set by your policy and state law, typically 60 days to 1 year. Check the appeal instructions printed on your denial letter for the exact deadline.

Should I hire a public adjuster for my property claim?

A public adjuster works for you, not the insurance company, and negotiates on your behalf. They typically charge 10 to 15 percent of the settlement. For claims over $10,000 where the insurer's estimate seems low, a public adjuster can often recover significantly more. For smaller claims, the fee may not be worth it. Make sure the adjuster is licensed in your state and check their references.

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