You Have the Right to Appeal: A Step-by-Step Guide for Patients Facing Health Insurance Denials

What should you do first after receiving a health insurance denial letter?

Start by thoroughly reviewing the denial letter to understand why your insurance company denied your claim. Then, compare the stated reason with your actual policy to determine whether the denial aligns with the terms and coverage details. Next, identify the deadline to file an appeal—these deadlines are time-sensitive and missing them could result in losing your right to challenge the denial.

It’s strongly advised to work with both your doctor and an attorney at this stage. Begin collecting all relevant documentation, including medical records and letters from healthcare providers. If your condition is complex or critical, such as in cases involving advanced or terminal illnesses, you may need letters from multiple physicians to support the necessity of the proposed treatment.

Your appeal should be carefully prepared and supported with medical evidence, a clear explanation of medical necessity, references to your insurance policy, and any applicable laws. Once complete, submit the appeal through a trackable method (such as certified mail or fax) and note the deadline by which the insurance company must respond—typically 72 hours for expedited reviews, 30 days for standard pre-authorization reviews, and 60 days for post-service denials. Document every step of the process, including calls, letters sent, and responses received.

What is the difference between an internal appeal, external review, and filing a lawsuit?

An internal appeal is the first level of review within the insurance company. Typically, your case is reviewed by an internal appeals department, which is still part of the same company that issued the denial. While some insurers offer a second level of internal review, both levels are ultimately overseen by employees of the insurance provider, making impartiality a concern.

An external review, on the other hand, involves an independent third-party agency. If requested, your insurer must arrange for an unbiased external party to evaluate your appeal and all supporting documents. This decision is binding—if the external reviewer overturns the denial, the insurer must comply.

Filing a lawsuit becomes an option when both internal and external reviews are exhausted and the denial remains in place. This is often considered a last resort. Legal action varies depending on the type of insurance: state lawsuits typically apply to marketplace plans, while employer-sponsored plans fall under federal ERISA regulations. In employer-plan cases, appeals are mandatory before suing; failure to appeal could result in dismissal.

When does it make sense to file a lawsuit against your insurance provider?

If your appeal has been denied at all levels—including external review—and your doctor strongly disagrees with the decision, you may consider filing a lawsuit. This step is a significant decision typically made with the support of legal counsel after evaluating the policy terms, denial reasons, and potential outcomes.

For employer-sponsored plans governed by ERISA, lawsuits proceed as bench trials without a jury. State-based plans may result in jury trials if a settlement isn’t reached. While cost is a major consideration, some cases allow patients to recover attorney’s fees if they win, making legal action financially worthwhile.

Every case is unique, so a thorough legal analysis is crucial. If there’s a reasonable chance of success and significant medical needs at stake, filing suit may be justified.

What happens if you miss the appeal deadline?

Missing an appeal deadline doesn’t always eliminate your options, but it can significantly limit them. In federal cases governed by ERISA, failing to file a timely appeal could mean losing your right to sue. However, if there's a valid reason for the delay—such as hospitalization or administrative error—it may be possible to argue for reinstatement of rights, depending on the policy and circumstances.

It’s important to note that some policies do not mandate an appeal before legal action, but employer-sponsored plans usually do. Review your policy carefully and consult an attorney if you’ve missed a deadline to understand if any recourse is still available.

What common mistakes should patients avoid when filing an appeal?

One of the most common and damaging mistakes is submitting a simple, unsupported letter. Patients often write brief notes stating they disagree with the denial without providing medical documentation or detailed reasoning. Worse, some unintentionally include admissions or statements that weaken their case.

Avoid self-blame or speculative reasoning in your appeal. Insurance companies can and will use written statements against you. Work with an attorney to ensure your appeal is accurate, comprehensive, and persuasive. Supporting documentation from doctors, clear references to your policy, and a professional presentation can significantly improve your chances of success.

How can patients feel more empowered during the appeal process?

Navigating the appeals process can feel overwhelming, especially when dealing with a serious health issue. The key to empowerment is organization and professional guidance. At our firm, we start by breaking the situation down step by step—asking questions, collecting documents, and identifying the specific needs of the case.

As patients begin to see that they do have evidence, medical support, and legal standing, they often feel less intimidated. It becomes less about being at the mercy of a faceless insurance company and more about asserting their right to coverage and care. With a clear strategy and the right support, patients can regain control and fight back effectively.

Need help with a health insurance denial?

Visit healthandmedicinelawfirm.com to connect with Maria T. Santi, Esq. and her team. They specialize in guiding patients from confusion to clarity—and from denial to approval.