If a claim is denied, you can appeal by first understanding the reason in the denial letter, then gathering more evidence, filing an internal appeal with the insurer, and potentially moving to an external review or involving your state's insurance department or an attorney if it's still denied, as you have the right to challenge the decision. Don't just pay out-of-pocket; follow the insurer's process to get a fair review, often starting with clarifying paperwork errors.
If your resubmitted claim is denied and you believe the denial was improper, you may appeal the decision according to the carrier's guidelines. Make sure you know exactly what information you need to submit with your appeal. Keep in mind that appeal procedures may vary by insurance company and state law.
Steps to Take After a Claim Denial
The first thing you can do is ask the insurer to review its decision. It is well within your rights to ask for them to undertake an “internal review”. If possible, we recommend you provide any additional evidence and/or arguments to support your insurance claim.
But a claim denial does not necessarily mean you will ultimately have to pay for everything out of pocket. There are steps you can take – including filing an appeal – that may help you get the denial overturned.
When talking to an insurance adjuster, avoid admitting fault, speculating on the cause or extent of injuries/damages, giving recorded statements without legal advice, and volunteering extra information like past injuries or unrelated details, as anything said can be used to minimize your claim; instead, stick to basic facts, remain polite but brief, and consider getting legal counsel. Don't sign anything without review, and avoid saying you're "fine" or "okay" immediately after an incident.
In 2023, roughly one third of all in-network claims made to AvMed were denied by the medical insurance company. In this year, AvMed and United HealthCare were the medical insurance companies with the highest denial rate for in-network claims in the United States, at 33 percent each.
Since insurers base premiums on how likely policyholders are to file a claim, a claim that's denied can cause your rates to go up — though not as much as if the claim was approved. Even discussing a claim with an agent, without actually filing it, can impact your premiums.
You can ask that your insurance company reconsider its decision. Insurers have to tell you why they've denied your claim or ended your coverage. And they have to let you know how you can dispute their decisions.
While most claims remain on your record for five to seven years, the exact length of time depends on a few factors, like your insurance company and the severity of the claim. Usually larger, more expensive claims stay on your record for longer, whereas smaller, less expensive claims might be removed earlier.
If you are still unsatisfied with the decision, you can appeal the insurer's decision to the Financial Ombudsman – within 6 months of receiving the insurer's response to your complaint. The Financial Ombudsman is an independent organisation that can help you resolve disputes with your insurance company.
What they won't tell you is that their primary job is to save their company money—often at your expense. Insurance adjusters are not your advocates. They're trained professionals whose performance is measured by how much they save their company. Every dollar you don't receive is a dollar their employer keeps.
8 Red Flags That Insurance Companies Aren't Going to Cover Your Bills
Claim not filed on time (aka: Timely Filing)
If a proper claim is submitted, but it's not within the timing window, it may result in a denial. It is recommended that you check with your Payers regarding their filing deadlines.
Here are some tips for handling rejected claims:
What Happens After a Denial? Once your claim is denied, the insurance company will send a formal letter explaining the reasons. You should review this letter carefully with a Los Angeles personal injury lawyer to identify any inaccuracies or bad faith practices.
When a claim is submitted electronically, an insurance payer can reject it if any errors are detected or if there's invalid information that doesn't match what they have on file. Rejected claims need to be resubmitted with the correct information to be processed.
Contact your insurance company
If you still feel that your claim was unfairly rejected, contact your insurance company and tell them you're unhappy. All insurance companies are required by law to have a formal complaints process, so following this process will get you the fastest possible resolution.