Getting a denial letter from your health insurance company can feel like a punch to the gut. You’re dealing with medical issues, mounting bills, and suddenly the coverage you’ve been paying for isn’t there when you need it most. These denials happen more often than most people realize, and they’re not always justified.
Our friends at The Law Office of Bennett M. Cohen discuss how approximately one in seven claims gets denied by insurers each year. When you’re facing a wrongful denial, a health insurance claim denial lawyer can be your strongest advocate in challenging the decision and securing the benefits you’re entitled to receive.
Why Insurance Companies Deny Claims
Insurance companies deny claims for various reasons, and some are more legitimate than others. Common grounds for denial include:
- Lack of medical necessity
- Services deemed experimental or investigational
- Out-of-network providers
- Missing or incomplete documentation
- Pre-existing condition exclusions (though the Affordable Care Act has limited these)
- Coverage lapse or policy exclusions
Sometimes these denials are valid. Other times, they’re based on flawed interpretations of policy language or incomplete reviews of medical records.
The Appeals Process Can Be Overwhelming
Most health insurance policies require you to go through an internal appeals process before taking legal action. This typically involves multiple levels of review within the insurance company itself. You’ll need to submit written appeals, gather supporting documentation from your healthcare providers, and meet strict deadlines.
The process is deliberately complex. Insurance companies count on people giving up. We’ve seen countless cases where legitimate claims were initially denied, only to be approved after persistent appeals and legal intervention.
When Legal Help Becomes Necessary
If your internal appeals are exhausted and your claim is still denied, you have options. Many states require external review processes where an independent third party examines your case. Beyond that, litigation may be necessary.
ERISA (the Employee Retirement Income Security Act) governs most employer-sponsored health plans. This federal law creates specific procedures and limitations for challenging claim denials. If your coverage comes through your employer, your case likely falls under ERISA jurisdiction.
Individual policies purchased through state or federal exchanges operate under different rules. State insurance regulations and consumer protection laws may provide additional avenues for relief.
What We Look For In Denied Claims
When reviewing a denied claim, we examine several factors:
- Whether the insurer followed proper procedures in reviewing your claim
- If the denial decision was arbitrary or based on substantial evidence
- Whether policy language was correctly interpreted and applied
- If all relevant medical information was considered
- Whether the denial violates any state or federal regulations
Insurance policies are contracts. When companies fail to honor their contractual obligations, they can be held accountable.
The Value Of Medical Evidence
Strong medical evidence is the foundation of any successful appeal or lawsuit. We work closely with your treating physicians to obtain detailed statements explaining why the denied treatment or service was medically necessary. Expert opinions from specialists in your condition can also strengthen your position.
Documentation matters tremendously in these cases. Every medical record, test result, and physician note becomes a piece of the puzzle we use to build your case.
Fighting For What You’re Owed
Insurance companies have teams of lawyers protecting their interests. You deserve the same level of representation protecting yours. We understand insurance policy language, medical terminology, and the legal frameworks that govern these disputes.
Bad faith denials, where insurers act unreasonably in denying claims, may entitle you to additional damages beyond the claim amount itself. Some states allow recovery of attorney fees and other costs when insurers behave badly.
If you’re struggling with a denied health insurance claim, don’t face this fight alone. We can review your denial, explain your options, and help you take action to secure the coverage you need.