Have you or a loved one experienced a denied health insurance claim? If so, you’re not alone. According to the Commonwealth Fund, one in every four Americans has had a health insurance claim denied. Ensuring you get the coverage you deserve helps to understand why claims are denied and what actions can be taken.

What Happens When An Insurance Company Refuses to Pay Your Claim?

Health insurance should protect you from the high cost of medical bills, but sometimes your insurer will refuse to pay a claim. This can be frustrating and confusing, so it’s important to know what to do if this happens. Reaching out to an Injury Lawyer in NJ can help shed some light and help you navigate your next steps.

If your insurance company refuses to pay a claim, they may give you a reason, such as the service or treatment was not medically necessary. However, this is often not the case, and insurers will use any excuse to avoid paying out claims. In some situations, the insurance company may even accuse you of fraud. If you feel the insurance company is acting unfairly, an injury lawyer can help you get to the bottom of it.

Reasons Why Your Health Insurance Claim Got Denied:

Your doctor or other medical care provider did not participate in your health plan. This means that they are considered “out-of-network” and usually won’t be reimbursed by your insurance company.

Your insurer did not consider the service or treatment you received “medically necessary.” This is a common reason for claim denials, but it can be hard to prove that the care you received was necessary.

You did not receive pre-authorization before treatment or surgery. Before you have any medical treatment, it’s best to check with your insurance company for pre-authorization so that there are no surprises when the bill comes due.

The claim was submitted incorrectly on paper forms by either your doctor’s office or yourself and missing a diagnosis code.

The insurance company has a “medical necessity” policy that denies claims for services or treatments that are not considered essential to your overall health and well-being.

If you feel that your health insurance claim was wrongfully denied, reach out to your lawyer for help. They can review the situation and determine the best course of action.

Types Of Claims Denial Appeals

Appeals for health insurance claims can be filed for a variety of reasons. The most common type of denial is when an insurance company rejects a claim because it does not meet the policy’s terms and conditions. Other reasons for denials include:

  • Incorrect information on the application
  • Not enough documentation to support the claim
  • The claim was filed too late
  • The service or treatment was not pre-approved
  • The policy does not cover the type of service or treatment received

In most cases, you have the right to appeal a health insurance claim denial. Your insurance company will provide information on how to file an appeal. Be sure to follow all of the instructions carefully, and include any supporting documentation.

The appeals process can be complicated and frustrating. It is essential to stay organized and keep track of all communications with the insurance company. If you need help, you can contact an attorney or healthcare advocate for assistance.

There are several types of appeals that you may file: 


This is the first step in the appeals process. You can file a reconsideration request if you disagree with the insurance company’s decision to deny your claim.

Administrative Hearing

This is a formal hearing that is held before an administrative law judge. You can request an administrative hearing if you are not satisfied with the outcome of your reconsideration appeal.

Civil Court Action

You can file a civil court action if you are not satisfied with the outcome of your administrative hearing.

External Review

This process allows you to appeal a health insurance claim denial to an independent review organization.

Understanding your rights and the appeals process is essential before filing a request.

How To Appeal On Denied Insurance Claim

Following the legal process for appealing, a denied health insurance claim can be daunting, but it’s important to remember that you have rights. Here are the steps you need to take to make sure your case is heard:

  1. File an appeal with your insurance company. This should be done in writing and within a specific timeframe (usually 60 days).
  2. Submit all supporting documentation along with your appeal. This includes any medical records, hospital bills, and other evidence that supports your claim.
  3. Wait for a response from the insurance company’s appeals department. They may approve part or all of what you requested; deny it completely, or ask for additional information before making their decision on what action should be taken next. If this happens, make sure you gather all requested documents and submit them within the specified timeframe so that your appeal has its best chance at success!
  4. If you’re denied again after the second review of your case file, then it’s time to escalate things by filing an appeal with the state insurance commissioner’s office. This is a formal process, and you’ll need to provide all the same information as you did with your insurance company’s appeals department.

Keep in mind that every state has its laws and regulations regarding health insurance claims, so make sure you’re fully aware of what’s required to have the best chance at success! Don’t just follow what other people have done.

Some states require an appeal hearing with a panel of experts. In contrast, others ask for written submissions from both sides before deciding whether or not they’ll overturn the denial based on new information presented during this process (i.e., hospital bills). What happens if the state insurance commissioner denies your appeal?

Final Words

In some cases, you may be able to take the case to court. This complex and expensive process should only be pursued as a last resort. Talk to an attorney specializing in health care law to learn more about your specific situation and what steps you can take next.