Appealing the Denial of an Insurance Claim - The Internal Appeals Process
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Appealing the Denial of an Insurance Claim

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Appealing denied insurance claims requires an insured to go through the internal appeals process.

When your insurance claim is denied by your provider, be it disability, health, property, life, etc., you have several options. The law entitles you to challenge the denial via one of a number of processes. Your insurance plan will typically include the protections and limitations, including what challenges are available.

If your policy is governed by ERISA, then you are required to first go through your administrative options, meaning the internal appeals process, before bringing a civil lawsuit against your insurer for coverage. Non-ERISA policies, however, do not carry that limitation. Policyholders can choose to immediately file a lawsuit rather than going through the process of an internal appeal.

The internal appeals process for appealing claim

The federal Employee Retirement Income Security Act of 1974 (ERISA) sets minimum standards for most established retirement and health plans. ERISA requires that providers have internal processes for you to appeal any adverse coverage determinations. The appeals process generally involves three steps:

  1. You file a claim, i.e., a request for coverage,
  2. The company denies your claim. Insurers must explain in writing why your claim was denied, and must do so within certain time periods:
    • Within 15 days if you are seeking prior authorization for a treatment
    • Within 30 days for medical treatment you have already received
    • Within 72 hours for urgent care cases
  3. You file an internal appeal. You must do so within 180 days (6 months) of the denial of your claim.
    • You must complete all forms required by the insurer, and you can submit any additional information you want the insurer to consider (e.g., a letter from your doctor). The California Consumer Assistance Program can file an appeal for you, or you can do it yourself or with the help of your attorney.

How long does an internal appeal take?

Federal regulations set requirements for insurance companies to complete your appeal. Appeals for medical treatment coverage must be completed:

  • Within 30 days if you have not yet received the service
  • Within 60 days if you have already received the service

For coverage other than medical treatment, there are different time frames. For example, under ERISA, disability claim appeals must be resolved within 45 days, unless “special circumstances” warrant extending the time period for another 45 days. The provider must notify the insured that they are using their “special circumstances” extension, and explain why.

After the internal process

Typically, you will appeal to two different levels within the insurance company and then to an independent body such as a medical board. If your claim is still denied, you can then bring a private lawsuit against the insurance provider.

Understanding which appeals process applies to your policy and how to file an appeal properly can be a complex and technical matter. If you believe your insurance company has inappropriately denied you coverage, treated you unfairly, or generally acted in bad faith, call the experienced and compassionate Los Angeles insurance attorneys at Gianelli & Morris at 213-798-4860.

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