Leif Adamec Rydenfalk
Your insurance claim was denied
A denial is the insurer's first answer, not the last one. Many are reversed on appeal because a form was missing, a code was wrong, or nobody read the doctor's note. The appeal works when it answers the exact reason they gave, in writing, before the deadline.
This page covers US rules. In Sweden, Konsumenternas Försäkringsbyrå gives free advice and Allmänna reklamationsnämnden (ARN) reviews disputes. This is what I'd do, in order. I'm not a lawyer, and if you'd rather not deal with it, send it to me.
Get the reason in writing
Ask the insurer, in writing, for three things: the denial letter with the exact policy clause they rely on, your full claim file (notes, reviews, the adjuster's or medical reviewer's report), and the appeal deadline. You are entitled to the file for health and employer disability plans, and most other insurers hand it over when asked.
Keep the policy number, the claim number and every date in one place. You'll need all of them.
Know your deadline
| Health insurance | 180 days from the denial to file an internal appeal. If they deny again, you can ask for an external review by an independent reviewer, usually within 4 months. Urgent care gets a fast track, decided within 72 hours. |
|---|---|
| Disability through work | Usually 180 days to appeal (ERISA plans). Put everything in this appeal: if it ever goes to court, the judge mostly looks at what was in the file. |
| Auto and home | Deadlines are in your policy. A dispute over how much, not whether, often has an appraisal clause: each side picks an appraiser and an umpire settles it. |
What goes in the appeal
- Who and what. Your name, policy number, claim number, and the date of the denial.
- Their reason, then yours. Quote the reason they gave and answer it point by point. If they say "not medically necessary", a letter from your doctor saying why it was necessary carries the most weight.
- The proof. Medical notes with dates, the doctor's off-work note, photos, repair estimates, receipts. List each one at the end of the letter.
- Consistency. If they approved part of the same event (they paid the accident policy but denied disability for the same injury), say so. Two answers to one injury are hard for them to defend.
- What you want and by when. Pay the claim, the amount, and a date for their answer.
If the appeal fails
File a complaint with your state's insurance department. It's free, it's online, and the insurer has to answer the regulator in writing, which often moves a stuck claim. For an emergency room visit billed as out of network, the federal No Surprises Act limits what you can be charged; ground ambulances are not covered by it, but several states protect those too.
Big amounts, a court date, or an insurer that has brought in its own lawyer: that's the point to get a lawyer, and I'll tell you so.
Or hand it to me
Send me the denial letter and what happened. I write the appeal around their exact reason, you sign and send it, and I keep track of the deadlines and the replies. You get a fixed price before I start.
