How to fight an insurance claim denial.

Step by step guide to fight a denied medical claim by your insurance company.

Your doctor examined you in person and together you made a decision to try a medication. Your insurance company denied your claim because their doctor, whom you don’t know and have never seen, said “nope, you don’t need that.”

Fight that B.S. You deserve the care your doctor recommended.

Insurance companies are getting heartless. I recently read about a family receiving a denial for the medication for their daughter on BlueSky. The medication costs over $20,000 per month. Without it, their little girl will die. The insurance company had been covering the medication. She had been taking this medication and has been monitored by her physician prior to this denial. Now, out of the blue, the insurance company has said they won’t pay.

Many Thanks to @rahaeli.bsky.social

Here’s how you fight back.

Everything must be in writing. By all means, type it on your computer, but then print it and sign. Keep copies for yourself and send it registered mail to your insurance claims department. You can also email the signed letter and let them know the paper signed version is on the way via registered mail.

Ask for the following:

1. The name, board specialty and license number of the doctor making the determination the treatment was not medically necessary.
2. Request copies of all materials they relied on to make their determination
3. Proof the doctor making the determination has maintained registration in your specific state and documentation of their completion of all their continuing education requirements
4. Request the aggregate rate at which similar treatments are denied vs approved by the specific doctor being used for peer review

You are not entitled to “all” of these things in most states, but you are entitled to some of them. Nothing says you can’t ask for all of it, though. So ask! It makes them uncomfortable.

This is, she says, a wildly successful tactic, because if the insurance company answers them honestly, it gives you evidence that the "doctors" making these determinations are practicing medicine out of scope, without proper licensing and qualifications, in areas they are not competent in.

ValuePenguin has a great article detailing the insurance companies with the most denials, those with the least denials, and how to appeal the denied claim. https://www.valuepenguin.com/health-insurance-claim-denials-and-appeals#worst