What to Do When You Disagree with a Denied Health Insurance Claim
by Lauren Pezzullo
What to Do When You Disagree with an Insurance Claim Decision
You filed your insurance claim, waited for the decision—and then got the bad news. It was denied, or paid out way less than you expected. So what now?
First things first: don’t panic, and don’t assume this is the end of the road. You have the right to challenge an insurance company’s decision, and there’s a clear process to help you do it. Whether it’s health, auto, home, renters, or life insurance, the steps are surprisingly similar.
In this guide, we’ll cover why claims get denied or underpaid, the steps to dispute a decision, sample scripts for appeals, common mistakes to avoid, and how long the process usually takes. Let’s dive right in!
Step 1: Read the Denial or Payout Letter Carefully
Before you do anything else, start by reading the letter your insurance company sent. Most denial or payout letters should tell you:
- The amount approved (if anything)
- Why the claim was denied or reduced
- What your rights are or what your next steps should be if you want to appeal
Quick tip: Insurance companies, especially health plans, have to tell you why a claim was denied, and they’re required by law to explain it in writing. If their explanation doesn’t make sense, call and ask for clarification in writing.
Step 2: Call and Ask for Details
Once you’ve reviewed the letter, your next move is to talk to someone at the insurance company. This isn’t about arguing your side right now. Instead, you’re just gathering information. Here’s a sample script of what you cant say:
“Hi, I received a denial letter for my [type of insurance] claim, and I’d like to understand what led to that decision. Can you walk me through the specific part of my policy or documentation that caused the denial?”
Make sure to take notes during the call, including:
- The name of the person you spoke with
- The date and time of the call
- What they said and what they advised you to do next
Sometimes, an insurance claim denial will result from something small, like a missing document, that you can fix right away. Other times, it might come down to your insurer interpreting the policy in a way you don’t agree with—which leads to the next step.
Step 3: Gather Your Supporting Documents
If your insurer still won’t budge after the phone call, it’s time to build your case. Here’s what you’ll need to collect:
- A copy of your full policy (including exclusions or endorsements)
- All emails, letters, or messages between you and your insurer
- Proof to back up your claim—photos, receipts, repair estimates, medical records, police reports, etc.
- Second opinions or expert reviews, if applicable
Look closely at your policy’s wording. For example, if your homeowners insurance says it covers “sudden and accidental water damage” and you’ve got evidence that’s exactly what happened, make a note of it in your appeal.
Step 4: Submit a Formal Appeal or Dispute
If the issue isn’t resolved after your call, you’ll want to submit a formal appeal or request for reconsideration. Most insurers have an internal appeals process you’ll have to follow. And if this is a health insurance claim, federal law actually requires them to offer one.
- How to submit it:
- Follow the appeal instructions in your denial letter
- Use the insurer’s online portal, if available
- Include your supporting documentation
- Be clear, professional, and stick to the facts
- What to include in your appeal:
- Your claim number
- A clear, professional explanation of why you believe the decision was wrong
- Specific references to your policy
- Any documents that support your case
- Example appeal letter intro: “To Whom It May Concern: I’m writing to formally appeal the denial of claim #123456 for [brief description]. Based on the terms of my policy and the evidence provided, I believe this claim should be covered. Please find the supporting documents attached.”
- End with a clear request: “I respectfully request a reconsideration of this decision and ask that a corrected payment or detailed explanation be provided within 30 days.”
Step 5: Know the Timeline
The amount of time you’ll have to wait for a decision depends on the type of insurance you’re dealing with, but here’s a ballpark timeline based on the type:
- Health insurance– 30 to 60 day wait (or longer for external appeals)
- Auto or Homeowners insurance– 15 to 30 days for a response (varies by state)
- Life insurance– Up to 60 days, sometimes longer
If you don’t hear back within that timeframe, follow up with a polite but firm reminder like this one:
“Hi, I submitted an appeal for claim #123456 on [date]. I’m following up to ask when I can expect a decision. Please let me know if any additional documentation is needed.
Step 6: Escalate if Necessary
If your insurer sticks to the denial, or ignores your appeal entirely, you still have options. Here’s what you can try next:
- State insurance department – File a complaint with your state’s insurance commissioner. They may be able to step in and investigate to help resolve the claim decision.
- Independent review (health insurance) – If your health insurance appeal is denied, you have the right to request review by an Independent Review Organization (IRO), an outside medical expert chosen by your state insurance regulator or HHS. The insurance company is usually obligated to go along with their decision. How to request one: Your denial letter will explain how to start an external review, but you can also find instructions through your state insurance department.
- Appraisal or mediation (homeowners/auto) – Most home or car insurance policies let you bring in a neutral person to help settle a dispute without going to court. In an appraisal, each side picks an appraiser, and those appraisers agree on a neutral umpire if needed. For mediation, your state insurance department can often connect you with a neutral mediator.
- Legal action – As a last resort, you can consult a lawyer—especially if your claim involves a significant amount of money. Just remember, legal action takes time and may not be worth it for smaller claims.
Common Mistakes to Avoid
Here are some helpful tips of what not to do:
- Missing deadlines – Always check how long you have to appeal, because some policies only give you 30 or 60 days to appeal a claim.
- Letting your emotions take over – Of course it’s frustrating to be denied, but an angry email will rarely help your case. Keeping things calm, factual, and professional will go a long way in helping your side.
- Skipping the fine print – Read your policy carefully—even the really boring parts. This may be where you find the exact language you need to support your appeal!
- Giving up too soon – Plenty of denials are successfully overturned, especially when backed by clear documentation and persistence.
Final Thoughts: Stay Organized and Persistent
Disputing an insurance claim decision isn’t fun, but it can absolutely be worth it. The key is to stay organized, calm, and persistent. Start by understanding the “why” behind the denial, then build a strong case based on your policy and supporting documents. Even if you don’t win your dispute, going through the process can teach you a lot about your coverage—and it might help you choose a better policy in the future. And if you are shopping for new insurance, keep an eye out for:
- Strong customer reviews (especially for the claims process)
- Clear and transparent policies
- Optional coverage add-ons that fit your needs
- Strong financial ratings
FAQ’s about Insurance Claims
Frequently Asked Questions
Why was my health insurance claim denied?
Common reasons include coding errors, missing documentation or preauthorization, out-of-network providers, plan exclusions, or filing after the deadline.
Can I appeal a denied claim?
Yes. Most plans allow internal appeals—and if that fails—an external, independent review when available in your state.
What documents do I need for an appeal?
Your denial letter, EOB, itemized bill, medical notes, referrals or prior authorizations, and a concise appeal letter summarizing medical necessity.
How long do I have to appeal?
Deadlines vary by plan and state. Check the denial letter for the exact window and submit as soon as possible to avoid missing it.
Will appealing affect my coverage?
No—appeals are a member right to challenge a determination and shouldn’t jeopardize your coverage.
Get Covered—Start with a Free Health Insurance Quote
No one wants to overpay for insurance, but the truth is, many people do—just because they don’t compare their options. A few minutes of your time could mean saving a lot. Get a free online insurance quote today and see how much you could save on your insurance.
- About the Author
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Lauren Pezzullo is an insurance content strategist and consumer trends analyst. She has led editorial teams at major brands and written for the Center for Health Communication at UT Austin. Her work covers home, auto, and health insurance topics.
