Kajko, Weisman & Colasanti, LLP

How can you appeal a health insurance claim denial?

If you count yourself among the many Massachusetts residents who have ever filed a health insurance claim and received a denial in response, know that denied claims are not at all uncommon. In fact, many insurance disputes arise because policy holders believe insurance companies are acting in bad faith when denying their claims. If this describes your situation, you may understand all too well just how upsetting it is when your insurer denies a valid claim and leaves you panicking about how you will pay for necessary care.

Per Healthcare.gov, one of the first things you should do after receiving notification of a health insurance claim denial is contact your insurance company for a thorough explanation. Insurers must provide this to you, and they must also do so if they decide to no longer cover you. If your insurance company gives you an explanation about why it denied your claim, but you dispute the reasoning or still believe your claim has merit, you can appeal it through one of two methods.

Your first option is to file what is known as an internal appeal. Generally, this entails your insurer taking a comprehensive second look at your claim and closely reviewing its decision and reasoning in denying your claim. The process can take time, but in emergency situations, your insurer typically must work with you to move things along more quickly.

Your second option involves requesting something called an external review. As the name suggests, this involves having an impartial third party look at your claim to determine whether your insurance company acted in bad faith when denying your claim. Remember, a claim denial does not necessarily mean you are out of options - it may just take a bit more time to find a solution that meets your needs.

This information about health insurance disputes is informational in nature and not a substitute for legal advice.




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