How do I appeal a denied health benefits claim?

On Behalf of | Mar 5, 2020 | Erisa & Employee Benefits |

Insurance providers seem to have a lot of power. When you go in for treatment and submit a claim, it is up to them to decide whether that care is covered.

A provider does not always make the right decision. There are times when a health benefits claim is wrongly denied. In these situations, there is generally a way to appeal. Here is where to start.

The basics of a denied claim

Most people that receive health insurance through their employer are part of a group health plan. A federal law known as ERISA governs how these plans are administered. That is what we will be focusing on in this post.

You should receive a notice that your health benefits claim has been denied. As explained by the Department of Labor, a plan can deny a benefits claim for a few reasons. Examples include:

  • You were not eligible for benefits
  • You received services not actually covered by the benefits plan
  • You did not provide enough information in the claim

At this point, you should have at least 180 days to file an appeal. (The language in your summary plan description should have the exact figure.)

The internal appeals process

When appealing a denied health benefits claim, you must first go through the internal appeals process. This means following the procedure laid out in your plan description.

The first step is to gather information that supports your claim. You can request documents, records and other information relevant to your claim from your insurance provider. The provider should get these to you for free.

During this part of the process, it is important to submit evidence rebuffing the reason your claim was denied in the first place. It can also be beneficial to get help from a lawyer during this stage, as the evidence you choose to include here could be relevant down the line.

During this internal review, a new person will look over your claim, along with the additional information you provide. There may be one or two levels to this internal appeals process. If your appeal is successful, then you can move on. If your claim is once again denied, you may need to consider the next option: legal action.

Filing a lawsuit

Once you exhaust the internal appeals process, you can consider filing an ERISA lawsuit in federal court. These cases are often complex and can take quite a while to resolve. There are strict timelines and requirements that must be followed.

If you miss one, it could sink your entire case. It’s important to do everything possible to ensure you have the best chance at success.