Ask the Expert: Appealing a Health Insurance Claim Denial

Ask the Expert: Appealing a Health Insurance Claim Denial

For breast or ovarian cancer survivors or women at risk, an insurance claim denial can feel like a setback, but it can feel empowering knowing you have options. If you have a private health insurance and your insurance denies a claim payment or terminates health plan coverage, the following are two ways you can appeal.  

  1. Internal Appeal: Ask the insurance company to conduct a full and fair review of its decision. The process for internal appeals may vary depending on the carrier and type of insurance policy. To file an internal appeal, complete all forms that the health insurer requires, or write a letter to the insurer. Be sure to include your name, claim number and health insurance ID number. Submit any additional relevant information, such as doctors’ letters.
  2. External Review: If an internal appeal fails, ask for an independent medical review or external appeal by a third party. External review requests must be in writing and may need to be filed within 60 days. During the external review, a reviewer who is independent from the insurance company reviews the information and makes a binding decision regarding coverage and/or payment. Contact your state’s insurance department for more information on the external review process at https://www.naic.org/state_web_map.htm .

Shelly Rosenfeld is a Staff Attorney at the Cancer Legal Resource Center (CLRC), a national program of Disability Rights Legal Center.  CLRC provides free education and resources on cancer-related legal questions to cancer survivors, caregivers, and health care professionals.  For more tips or answers to cancer-related legal questions, contact the CLRC at 866-843-2572 or visit cancerlegalresources.org.

Disclaimer: Through this article, the author is not engaged in rendering any legal or professional services by its publication or distribution. It is not intended to be legal advice or establish an attorney-client relationship.

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