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How to Appeal a Denial Of Your Health Insurance Claim

Health insurance has been the key to quality healthcare for millions of Americans. Most plans allow for you to see the doctor of your choice, cover the cost of your prescription medications, and allow you to receive emergency care without being stuck with the entire hospital bill. However, there are times when health insurance companies refuse to approve certain claims. When this happens, many people tend to ignore their insurance carrier’s decision and simply think they have no choice but to either not receive the care they want covered, or foot the bill and pay for the care themselves.

Common Reasons Why Health Insurance Claims Are Denied

Our Miami insurance claim denial lawyers know how health insurance policies can be long, difficult to read, and not clearly communicated to the insured. Most people know what their deductible is and what their co-pays are, but that’s it. The list below demonstrates some common reasons why your insurance claims may be denied.


• The care you are seeking is not medically necessary.
• The care you are seeking is experimental.
• The care you are seeking is not covered by your insurance plan.
• You have a preexisting condition that precludes coverage (even though the
Affordable Care Act no longer allows insurance companies to discriminate based on preexisting conditions, it is still important to be aware that insurance companies have been notorious for doing this).

If your health insurance claim is denied, follow the steps below to go through the appeal process. You may find that your claim was denied by accident, the insurance company didn’t have sufficient information to properly determine whether or not your claim should be approved, or you may find that the healthcare you are seeking simply isn’t covered by your plan. Oftentimes, you may need the assistance of an attorney to ensure your insurance company is not wrongfully denying your claim in bad faith.

The Appeal Process

First Step – Contact Your Health Insurance Carrier

Call you insurance company right away. The sooner you take action, the greater the chance you have of resolving the issue and getting the coverage you need to pay for your medical care. While you certainly can contact your insurance provider by email or regular mail, it is best to speak with someone directly. You will likely have a much larger impact if you voice your concerns regarding your denied claim directly to an actual person.

Second Step – Internal Review of Your Denied Claim

After you contact your health insurance provider, there will be an internal review of your claim. The insurance company will look at various factors to determine whether or not the initial denial was legitimate or if a mistake was made.

Third Step – External Review of Your Denied Claim

If the internal review of your claim is not successful, you have the right to further appeal and have an impartial, third party review your claim. The third party will look at the issue from a blank slate and the insurance company cannot influence the third party’s investigation or final decision in any way. The external reviewer will then make a decision, either agreeing with the insurance company’s internal review, or reversing that decision and finding that your claim should be approved and your care covered under your insurance plan.

Fourth Step – Contact A Lawyer

Despite all of your efforts, you may find that your health insurance carrier simply will not approve a claim that you feel is medically necessary, and/or covered by your current health insurance plan, and an external review will come to the same conclusion. When you hit a bump in the road and you are not sure what else to do, an attorney experienced in insurance claim denial cases can help you fight the insurance company to get the coverage you deserve. Insurance companies want to collect as much money in premiums as possible, while at the same time limiting the amount they pay out for claims. It is not always fair, but you are not alone when going through the stressful process of fighting your health insurance company.

Contact Our Miami Insurance Claim Denial Lawyers Today To Schedule Your Free Consultation

Greenberg Stone and Urbano is a South Florida law firm employing attorneys with over 100 years of combined experience. Our Miami Insurance Claim Denial Lawyers have been successful in helping clients get the coverage they are entitled to under their health insurance plans. Our skilled attorneys have earned the name “Superlawyers,” designating them as some of the best lawyers in America. Our Miami Insurance Claim Denial Lawyers have also been rated “AV” by Martindale Hubbell and have been voted “South Florida’s Top Rated Lawyers” by the Miami Herald. They have also been invited to be members of Primerus, an international society of leading law firms. Call Greenberg Stone and Urbano today to schedule your free consultation to discuss your potential case. You may contact us through our website or call us at (888) 499-9700 or (305) 595-2400.

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