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Appealing Denial of a Health Insurance Claim

When your insurance claim is denied by your provider, be it disability, health, property, life, etc., you have several options.  You have the right to challenge the denial both internally with the insurance provider and externally via a lawsuit, should your appeal ultimately be rejected.  Insurance companies deny claim coverage for a variety of reasons, some legitimate and some in bad faith.  The health insurance claim denial attorneys at Gianelli & Morris will review your claims and help you build the strongest case for coverage.

The Internal Appeals Process

Federal law sets minimum processes that insurers must provide in responding to the denial of a claim.  There are typically three steps to a claim denial:

  1. You file a claim.  You or your healthcare provider file a claim requesting reimbursement for the costs of treatment or service
  2. Your health plan denies the claim.  Your insurer must notify you of the denial, in writing, and provide an explanation as to why your claim was denied.  They must notify you within certain time limits:
    1. If you are seeking prior authorization for treatment you have yet to receive, they must notify you of a coverage decision within 15 days.
    2. If you have already received treatment, they must notify you within 30 days.
    3. If you require urgent or emergency care, they must notify you within 72 hours.
  3. You file an internal appeal.  You have 180 days (six months) from denial of your claim to file your appeal.
    1. You can either complete the forms provided by your insurer and/or write an appeal letter to your insurance provider.  The letter must, at a minimum, include your name, claim number, and health insurance ID number.  We provide guidance on how to write an effective appeal letter, including what information and evidence to submit, how to get an effective letter from your doctor, and other advice.
    2. You can file an appeal yourself or with the help of an attorney.

If your insurance provider denies your appeal, you can then file for external review or sue the insurance provider.  The insurance denial appeal attorneys at Gianelli & Morris can explain your options.

How Long Do Internal Appeals Take?

Insurance companies are bound by federal laws and regulations to make a final decision regarding policy coverage within certain time limits.  Appeals for medical coverage are subject to the following time constraints:

  • If you have not yet received the medical treatment, the insurance provider must resolve the appeal within 30 days
  • If you have already received the medical treatment, the insurance provider must resolve the appeal within 60 days

Appeals concerning other types of insurance coverage are subject to different time limits.  If your claim involves both healthcare and, for example, disability, speak with an insurance bad faith denial attorney to explore your options and learn about the time frame for coverage decisions in your particular case.

Do I Need to Appeal Internally?

Policies governed by the federal Employee Retirement Income Security Act of 1974 (ERISA) require that you first appeal a coverage denial internally.  You cannot immediately file a lawsuit against your insurance provider.  If your policy is not governed by ERISA, however, you can choose to immediately file a lawsuit rather than waiting to go through the internal appeals process.  You may also seek other external review.  There are advantages to going through the internal appeal first, however.

Your appeal may be resolved much more quickly than a lawsuit, should your insurance provider find your arguments persuasive.  They may have simply made a mistake, or they may realize you are not going to take a bad faith denial lying down and choose to reverse course.

If you do file an internal appeal first and your insurer still denies your claim, they must provide you with an explanation of how to seek an external review.  Moreover, if your situation is urgent, you can request an external review even if you have not completed the internal review process, and you can ask for expedited review.

Speak with a knowledgeable insurance claim denial attorney to discuss your options and craft the best strategy to ensure you get coverage for your medical procedure.

Help is Available After Your California Health Insurance Claim is Denied

If you’ve had a claim for benefits rejected by your California health insurance provider, get seasoned and reliable help appealing your claim denial by contacting the Los Angeles insurance claim denial lawyers at Gianelli & Morris for a free consultation at 213-489-1600.

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