Health insurance is supposed to protect us when life throws a curveball. Yet, for many people, the shock comes when their insurer refuses to pay a claim they thought was covered. According to the Kaiser Family Foundation, nearly one in five in-network claims (18%) filed under Affordable Care Act marketplace plans were denied in 2022. That’s a significant number, and it shows just how common the problem has become.
The silver lining? A denial is rarely the end of the road. With patience, the right documents, and a clear understanding of your policy, many rejections can be overturned.
Why Insurers Say “No”
Sometimes denials happen because of technical slip-ups, and sometimes they stem from real limits in a policy. Common reasons include:
- Missing paperwork or incorrect billing codes.
- A treatment not listed under the plan’s coverage.
- Services done without prior authorization.
- Visiting an out-of-network doctor or hospital.
- Something as simple as a typo in your name or ID number.
👉 Always request the Explanation of Benefits (EOB). It’s the insurer’s written justification for the denial, and it’s the first piece of evidence you’ll need.
Step 1: Read the Denial Notice Closely
Your denial letter should spell out:
- The exact reason for the rejection.
- Which part of your policy they’re leaning on.
- How long you have to file an appeal.
Don’t just skim it. Highlight the key parts and keep it on file—you’ll need those details later.
Step 2: Double-Check Against Your Policy
Next, pull out your policy documents (yes, the ones we all tend to leave in a drawer). Look for:
- Coverage caps—like a limit on the number of therapy sessions.
- Exclusions—such as “experimental” or “cosmetic” treatments.
- Rules around what counts as “medically necessary.”
Sometimes, the insurer is correct. Other times, the denial comes from misinterpreting the terms.
Step 3: Collect Your Evidence
To strengthen your case, gather anything that supports why the treatment was essential:
- A detailed letter from your doctor.
- Test results, scans, or lab reports.
- Corrected hospital billing codes.
- Any referrals or prior approvals you obtained.
The stronger the medical evidence, the harder it is for the insurer to brush off your appeal.
Step 4: Submit an Internal Appeal
Insurers are legally required to offer an internal review. Depending on your policy, you may have anywhere from 30 to 180 days to file.
When writing your appeal:
- Be clear and factual.
- Reference the denial reason directly.
- Attach all supporting documents.
Think of it less like a complaint and more like presenting your case to a reviewer who wasn’t there the first time.
Step 5: Escalate to an External Review
If the insurer still says no, you don’t have to stop there. Under U.S. law, you can request an independent external review. This means an outside medical expert takes a fresh look at your case.
Here’s where persistence pays: studies show that 40% to 50% of denials are overturned during external reviews. That’s nearly a coin toss in your favor if you push through.
How Denials Play Out in Numbers
| Process Stage | Percentage | What It Means for You |
|---|---|---|
| Initial Claim Denials (2022) | 18% | Nearly 1 in 5 claims hit a snag |
| Internal Appeals Success | ~25–30% | A quarter are resolved at this stage |
| External Review Overturns | 40–50% | Many patients win when it leaves the insurer’s hands |
Pitfalls to Watch For
- Waiting too long and missing the deadline.
- Sending an appeal without medical backing.
- Forgetting to keep copies of letters, emails, or call notes.
Even something small—like noting the date and time of a phone call—can tip the scales if your case drags on.
Final Takeaway
A denied claim feels like a door slamming shut, but in reality, it’s just one step in a longer process. With documentation, persistence, and the willingness to challenge a first decision, you can often get the coverage you’re entitled to.
And if it gets overwhelming, remember you’re not alone. State insurance departments and patient advocacy groups can step in with guidance at little or no cost.