Insurance Appeals

The short version

If your health insurance denies a claim for medical services, you have the right to appeal that decision. This process allows you to ask your insurance company to reconsider, and if needed, have an independent expert review your case. Understanding these rights helps you challenge denials and ensure you get the healthcare coverage you're entitled to.

The law this is built on

Every point below comes from the authority named next to it. Verify the current text before relying on it.

• 29 U.S.C. § 1133

  This law requires plans to provide adequate notice in writing to any participant or beneficiary whose claim for benefits has been denied, setting forth the specific reasons for the denial and referencing specific plan provisions. It also requires a reasonable opportunity for a full and fair review by the appropriate named fiduciary of the decision denying the claim.

  Why it matters: This means your insurance company must tell you why they denied your claim and give you a chance to explain why you think they're wrong. It's the basis for your internal appeal rights.

• 42 U.S.C. § 300gg-19(a)(1)

  This section requires group health plans and health insurance issuers offering group or individual health insurance coverage to implement an effective internal claims review process for claim denials. It also requires them to include in their notices of adverse benefit determinations information about available internal and external appeal processes.

  Why it matters: This law ensures you have a clear process to challenge a denial directly with your insurer, and that you are informed about further appeal options if your internal appeal fails.

• 42 U.S.C. § 300gg-19(b)(1)

  This section requires group health plans and health insurance issuers to comply with standards for external review. These standards require an independent reviewer to look at certain denied claims if the internal appeal doesn't fix the problem.

  Why it matters: This means you have the right to an independent review of your claim denial, outside of your insurance company, which adds an extra layer of protection.

• 42 U.S.C. § 300gg-19(c)(1)

  This section states that an adverse benefit determination (a claim denial) for urgent care must be reviewed as soon as possible, considering your medical condition, but not more than 24 hours after the plan or issuer receives the request for review.

  Why it matters: If your medical situation is urgent, the law says your internal appeal must be handled much faster than for non-urgent claims.

Words you need to know

Adverse Benefit Determination

This is a formal term for when your insurance company denies your claim, reduces the amount they will pay, or decides you are not eligible for a specific health benefit.

Internal Appeal

This is your first step to challenge a denied claim. You ask your insurance company to reconsider their decision. The law requires them to have a process for this. (29 U.S.C. § 1133; 42 U.S.C. § 300gg-19(a)(1))

External Review

If your internal appeal is denied, you may be able to ask an independent organization (not part of your insurance company) to review your case. This is required by law for many plans. (42 U.S.C. § 300gg-19(b)(1))

Urgent Care Claim

A claim where applying the usual timeframes for review could seriously jeopardize your life, health, or ability to regain maximum function, or subject you to severe pain. These claims have much faster appeal timelines. (42 U.S.C. § 300gg-19(c)(1))

Rescission

This is when an insurance company cancels your coverage from the date it started, as if you were never insured. The law generally prohibits this except in cases of fraud or misrepresentation. (42 U.S.C. § 300gg-12(a)(1))

Your rights

• ✓You have the right to a clear written notice explaining why your claim was denied, including the specific plan rules used to make the decision. (29 U.S.C. § 1133)
• ✓You have the right to an internal appeal process to ask your insurance company to reconsider their denial. (42 U.S.C. § 300gg-19(a)(1))
• ✓You have the right to see the documents and information the insurance company used to deny your claim, free of charge. (29 U.S.C. § 1133)
• ✓You have the right to an external review by an independent organization if your internal appeal is denied. (42 U.S.C. § 300gg-19(b)(1))
• ✓For urgent care claims, you have the right to a faster appeal decision. (42 U.S.C. § 300gg-19(c)(1))

How the process actually works

1. 1
   Receive Denial Letter

   When your claim is denied.

   Your insurance company sends you an 'adverse benefit determination' letter. This letter must explain why your claim was denied, list the specific plan provisions, and tell you how to appeal. (29 U.S.C. § 1133)

2. 2
   Gather Information

   After receiving denial, before internal appeal.

   Collect all relevant documents, including the denial letter, medical records, doctor's notes, and any correspondence. You have the right to get copies of all documents relevant to your claim, free of charge. (29 U.S.C. § 1133)

3. 3
   File Internal Appeal

   Usually within 180 days of the denial notice.

   Send a written appeal to your insurance company. Clearly state why you believe the decision was wrong and include any supporting documents. The law requires your plan to have an internal review process. (29 U.S.C. § 1133; 42 U.S.C. § 300gg-19(a)(1))

4. 4
   Internal Appeal Decision

   Within 30-60 days for non-urgent claims; 24 hours for urgent claims. (42 U.S.C. § 300gg-19(c)(1))

   Your insurance company reviews your appeal. They must provide a decision in writing, again explaining their reasons and telling you about your right to an external review if they uphold the denial. (29 U.S.C. § 1133; 42 U.S.C. § 300gg-19(a)(1))

5. 5
   File External Review

   Within 4 months of the final internal appeal decision.

   If your internal appeal is denied, you can request an external review by an independent organization. This review is done by an impartial medical expert. (42 U.S.C. § 300gg-19(b)(1))

6. 6
   External Review Decision

   Generally within 45 days for non-urgent claims; 72 hours for urgent claims.

   The independent reviewer will issue a binding decision. If they side with you, your insurance company must cover the service. (42 U.S.C. § 300gg-19(b)(1))

Deadlines that can end your case

• File Internal Appeal
  180 days from the date you receive the denial notice.

  If you miss this deadline, your insurance company may refuse to review your appeal, ending your chances to challenge the denial.

• Internal Appeal Decision (Non-Urgent)
  30 days for pre-service denials (e.g., prior authorization), 60 days for post-service denials.

  If the plan does not respond within this timeframe, it may be considered an 'exhaustion of internal review,' allowing you to proceed to external review.

• Internal Appeal Decision (Urgent)
  24 hours after receiving the request for review.

  Faster response required to protect your health. (42 U.S.C. § 300gg-19(c)(1))

• File External Review
  4 months (120 days) after receiving the final internal appeal decision.

  Missing this deadline usually means you lose your right to external review, and the insurer's denial stands.

Common questions

How this changes by state

While federal laws like ERISA (Employee Retirement Income Security Act of 1974, which includes 29 U.S.C. § 1133) and the Affordable Care Act (which includes 42 U.S.C. § 300gg-19) set minimum standards for health insurance appeals, some states have additional consumer protections or slightly different appeal rules. For example, some states might have shorter appeal deadlines, or require external review for plans that are not covered by federal external review mandates. To find your state's specific rules, you should contact your State Department of Insurance or its equivalent.

When you need a lawyer

You might consider hiring a lawyer if your claim involves a very high dollar amount, if your health is in serious jeopardy, if the denial seems particularly unfair or complex, or if you've exhausted all internal and external appeals and still believe your insurer acted wrongly. A lawyer specializing in health insurance or ERISA law can help navigate complex legal arguments and represent you in court if necessary.

Do this today

• →Keep all denial letters and medical documents organized.
• →Review your health insurance policy documents to understand your plan's specific appeal procedures.
• →Contact your state's Department of Insurance if you have questions or need help understanding your rights or finding resources.