The Center for Consumer Information & Insurance Oversight
If an insurer won’t pay a claim for medical services, you have rights to appeal. Learn about your rights now and in the future.
What if my plan won’t pay for care I think should be covered?
- You can appeal and ask the plan to reconsider the denial. Other legal options may also be available to you. To learn more about your appeals rights under job-related plans, see What You Should Know About Filing Your Health Benefits Claim.
- If the plan still says no, you may be protected by “external review,” which allows you to ask an independent, expert third party to help resolve the dispute with your health plan. Find consumer assistance in your state to see if you qualify for this external appeal protection.
- If you are in a job-based plan, you may be required to appeal to your plan a second time before requesting an external review.
- If the external reviewer says the claim must be paid, your health plan will have to cover it.
- Your individual policy or your job-based plan’s “summary plan description” will tell you how to appeal disputes. Sometimes claims procedures are in a separate booklet that‘s handed out with a summary plan description. Read your policy or summary plan description and claims procedures.
For other questions about appealing a health plan decision, use our map to find consumer assistance in your state.
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