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The Process for Denied Health Insurance Claims

Problems within the health insurance industry are a hot topic. Even if you are covered through an employer-sponsored policy, health insurance claims denials are commonplace. Rather than accepting defeat and paying these costs out of pocket, find out the process for appealing denied health insurance claims.    

Health Insurance Claims Denials

You rely on employer-provided health insurance to protect you in the event of illnesses or injuries. Depending on the type of coverage you have, you may be contributing significant amounts of your own money for this coverage. Having your claim denied can come as a shock, but it is actually quite commonplace. According to studies conducted by the American Association of Retired People (AARP), more than 200 million claims are denied or disputed each year. Common reasons for this include: 

  • Administrative errors, such as not properly coding a procedure or submitting the wrong paperwork;
  • Patient procedural errors, such as not getting a referral;
  • Disputes over coverage, which often involve different types of treatments;
  • Disputes regarding procedures deemed not a medical necessity. 

Dealing With Your Denied Health Insurance Claim

The first step in dealing with a denied claim is to dispute it with the insurance company. If it is a problem with coding or other administrative errors, this may easily resolve the situation. In more complicated cases, you have the right to appeal the insurer’s decision. If it involves employer-provided health insurance, the Employee Retirement Income Security Act of 1974 (ERISA) governs the appeals process. Steps involved include: 

  • Reviewing the reasons for your claim denial. Insurers are required to send you a letter detailing the reasons why your claim is being denied. 
  • Informing them of your intent to appeal. The claims denial will list the date by which an appeal must be submitted. 
  • The insurance company reviews the matter and either approves or continues to deny your claim. While they have the right to request additional information from you in making their decision, there are strict timeframes that must be followed that vary based on the type of care you received. 
  • If your claim continues to be denied, you have the right to have your appeal heard before an impartial third party. In ERISA cases, this is typically an administrative panel or judge. 
  • If you continue to be denied coverage, you have the right to take your case to court. After exhausting all other options, you may be able to file a lawsuit against the insurance company. 

Our Chicago ERISA Attorney is Here to Help

If you are facing a denied health insurance claim, reach out to Bartolic Law. We guide you through the appeals process, providing the aggressive legal representation needed to protect your rights. Call or contact our Chicago ERISA attorney online and request a consultation today. 

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