How to Appeal a Health Service Denial By Your Insurance Company

Dealing with a health insurance company when you are denied benefits you believe you had can be confusing and downright frustrating.

However, if your insurance company denies your claim, you do have options.

Your Right to an Appeal

If your insurance company refuses to cover valid health services such as autism treatment, mental health treatment, plastic surgery after weight loss surgery or proton therapy, you also have the right to have the company’s denial appealed.

Steps to Filing an Appeal

1. Find out why your health insurance company denied your claim.
If you have PPO insurance, you likely receive EOB (Explanation of Benefits) reports. This can help you understand why you were denied.

Perhaps the EOB states that you were not covered because you used an out-of-network provider. Sometimes this could be a simple coding error and can be fixed easily by phone, othertimes the issues can be more complicated. If the latter is the case, you will need to find out the more complex issues behind your denial.

You can contact the Member Services or Customer Service phone number that is usually located on your health insurance card for more information. Be sure to have a copy of any EOB or denial letter to reference.

Keep a log of the date and time of your call, the name of the representative you spoke to (and phone number or extension, if available), all of the relevant information that was discussed and the outcome of the call.

Ask your insurance company to explain in detail what led to the denial of your coverage. Ask how to obtain your plan’s “Evidence of Coverage” or other documents explaining your full benefits that are covered under your plan. Sometimes this information is only available for you to review online.

2. File an internal appeal. If the customer service representative is not able to fix your coverage issue, ask how to file an appeal. This type of appeal, filed with your insurance company, is considered an internal appeal. Many times there are forms online for you to file an appeal.

When you fill out the form, either online or on paper, be certain to keep a copy of anything that you submit to the insurance company. Include any relevant documentation, including letters of medical necessity from your doctor, research studies to back up your treatment choice or anything else that you think will help support your appeal.

In most cases, you must file an appeal within 180 days (six months) of receipt of your denied insurance claim. If you have a health situation that is urgent, you may ask for an external review at the same time that you file your internal appeal.

3. If the insurance company denies your appeal, you can file an external review. You have 60 days from the date of your insurance appeal denial to file a written request for an external review, although some plans may allow a longer time.

An outside agency will review the terms of your denied insurance claim and your denied appeal. The external reviewer will review the decision made by your insurance company and can either uphold the insurance company’s decision or can decide in your favor. The health insurance company is legally bound to the decision made by the external reviewer.

Bad Faith Insurance Lawsuit Information

If your health insurance company denies a medically necessary treatment, such as autism treatment, mental health services, plastic surgery after weight loss or proton therapy, you may be eligible to file a bad faith insurance lawsuit. Sometimes claims are denied when there is coverage, other times the claim may be underpaid or there may be an excessive delay in payment.

Bad faith insurance attorneys are currently conducting an investigation to look into the practices of various California health insurance providers and can review your case at no charge.

Join a Free California Bad Faith Insurance Lawsuit Investigation

A bad faith lawsuit investigation has been launched into allegations that some California insurance companies are refusing to pay valid medical claims or offering to pay far less than the claim is worth. Some of the companies being investigated for potential violations include:

• Aetna
• Anthem Blue Cross
• Blue Cross of California
• Blue Shield of California
• Cigna
• Health Net
• Kaiser
• Secured Horizons
• United Healthcare
• WellPoint
• Others

If you or a loved one were denied coverage for autism treatment, mental health treatment, plastic surgery skin removal after weight loss, proton therapy for cancer, or some other medically necessary treatment, you may have a legal claim.

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