Understanding the process for appealing denied insurance claims

You still have options if a medical claim is denied by the insurer.

With the ever-increasing cost of health care, insurance coverage is critical to avoid medically-induced financial ruin. Consumers count on their insurance carriers to be there when they have a medical crisis or need, and to honor their contractual obligations when the consumer files a claim under the terms of his or her policy. When the insurance company instead breaches the contract and denies coverage, the consumer needs to know what steps to take.

Knowing when an insurer has wrongfully denied a claim

The first step is identifying when the insurer has wrongfully denied a claim. Having a basic understanding of one's insurance policy is, therefore, important. A good place to start is to read the Summary of Benefits and Coverage, which every insurer must provide by law.

Appealing a wrongful claim denial

Under Arizona law, insurance companies must provide their policyholders a process for appealing denied claims. Generally speaking, the appeals process involves two or three steps. If, upon reading the health insurance policy, doubts or questions arise about the basis for the denial, the policyholder should request an informal reconsideration from the insurance company. The insured should read the policy itself to understand the process for requesting reconsideration. The next step is a formal internal appeal. If the insurer continues to deny the claim after a formal appeal, the policy may require the insured to file another appeal with an independent third party.

A different appeals track applies to medical care that an insured urgently needs which the insurer has refused to cover. The first step in this process is filing for expedited medical review. If the insurance company denies coverage for medical or health-related services following such a review, the policyholder can have his or her treating physician submit a written appeal to the insurance company. If the insurer continues to deny the claim, the next step is to pursue expedited external independent review.

In appealing the denial of a claim or requesting review of proposed medical services, the insured should be as clear as possible in explaining why the claim or services should be covered under the terms of the policy, providing any evidence necessary to establish coverage. This means including as much relevant documentation as possible and supporting the claim with the language of the policy.

Following the necessary procedural steps

When health care is at stake, following an insurer's internal appeals process can naturally give rise to impatience. But successfully overturning a wrongful claim denial often requires certain procedural steps. It's important to understand how your insurance provider's process works, including any mandatory internal appeals. Although there are general requirements insurance companies must abide when offering an appeals process to policyholders, each insurer's process is different. If the insurer's process fails to result in a just outcome, speaking with an experienced insurance law attorney may be the next step.