Understanding your legal protections when dealing with health insurance denials and the appeals process.
Federal law guarantees you the right to appeal any insurance company decision to deny, reduce, or terminate coverage. This right cannot be waived.
Your appeal must be reviewed by a qualified medical professional who was not involved in the original denial decision. For clinical denials, the reviewer must have appropriate clinical expertise.
If your internal appeal is denied, you have the right to request an independent external review. The decision of the external reviewer is binding on the insurance company.
In urgent situations where waiting for a standard appeal could seriously jeopardize your health, you have the right to an expedited appeal process (typically resolved within 72 hours).
Your insurance company cannot:
Many states provide additional protections beyond federal law, including:
Check with your state's Department of Insurance for specific protections available to you.
Under the No Surprises Act, emergency services must be covered without prior authorization, even if the provider is out-of-network. You can only be charged in-network cost-sharing amounts.
Consider contacting these resources if your appeal is denied:
AppealGen ensures your appeal: