Under the Affordable Care Act and ERISA, every US patient has legally guaranteed rights when their health insurance claim is denied. These rights exist whether or not you know about them — and insurance companies are counting on the fact that most patients don’t.
These rights apply to most non-grandfathered health insurance plans sold in the United States — including employer plans, ACA marketplace plans, and most individual plans. They cannot be waived by your insurer or buried in fine print.
Federal law guarantees you the right to appeal any insurance company decision to deny, reduce, or terminate coverage — for any reason. You do not need to show cause or meet any threshold. Every denial is appealable. This right cannot be taken away from you.
Your appeal must be reviewed by a qualified medical professional who was not involved in the original denial. For clinical denials — including medical necessity and experimental treatment — the reviewer must have clinical expertise in the relevant specialty. The insurer cannot re-use the same reviewer who denied your claim.
If your internal appeal is denied, you have the right to request an independent external review by an organization with no financial affiliation with your insurer. The external reviewer’s decision is legally binding on the insurance company — if they rule in your favor, the insurer must cover the treatment. External review is free to patients.
In urgent situations where waiting for a standard appeal could seriously jeopardize your health or your ability to regain maximum function, you have the right to an expedited appeal. The insurer must issue a decision within 72 hours — not 30 or 60 days.
You have the right to request and receive — free of charge — copies of all documents, records, and other information relevant to your denial. This includes the clinical criteria the insurer used to make its determination. Insurers cannot withhold this information from you.
When your claim is denied, federal law requires your insurer to provide you with a specific set of information. If your denial notice is missing any of the following, you can request it directly from your insurer’s appeals and grievances department.
When you call your insurer about a denial, follow up every phone conversation with a written email or letter confirming what was discussed. Keep records of the date, time, and name of every representative you speak with. This documentation trail is admissible evidence if you escalate to external review or a state insurance commissioner complaint.
An internal appeal is a formal request to your insurance company to reconsider a denial decision. It is the first and most important step in the appeals process — and where most cases are resolved.
Under the ACA, you have a minimum of 180 days (6 months) from the date of the denial notice to file an internal appeal. Some states require longer windows. Always check your specific denial letter for the deadline that applies to your case. Missing this deadline means losing your right to appeal that denial entirely.
To give your internal appeal the best chance of success, see our step-by-step appeals guide for the complete documentation framework. The key elements are: a direct rebuttal of the denial reason, objective clinical evidence, treatment history, a clinical guideline citation, and a request for peer-to-peer review.
A poorly written internal appeal — one that doesn’t address the specific denial reason — creates a weak record for external review. Even if the internal appeal fails, the record you create now is what the external reviewer will evaluate. AppealGen structures your letter specifically around the denial reason and clinical evidence to maximize both internal and external review outcomes.
External review is one of the most powerful patient protections in US healthcare — and one of the least used. After your internal appeal is denied, you have the right to have your case reviewed by an independent organization completely separate from your insurer.
External review is available for denials based on:
External review is generally not available for purely administrative denials (e.g., failure to obtain prior authorization due to a procedural error unrelated to clinical necessity).
If your medical situation is urgent, you do not have to wait months for a standard appeal decision. Federal law requires expedited decisions within 72 hours for:
Submit your appeal with a cover letter that explicitly states: “I am requesting expedited review under applicable ACA regulations due to the following urgent circumstances: [explain the medical urgency].” Have your physician also submit a letter confirming the urgency. Without the explicit expedited request, the insurer may process your appeal under standard timelines.
If your health insurance comes through your employer, your plan is likely governed by ERISA — the Employee Retirement Income Security Act. ERISA plans have specific rights and protections distinct from ACA marketplace plans.
If your employer’s plan is self-funded (which is common for large employers), state insurance laws do not apply — only ERISA and federal law. The presence of “ERISA” language in your plan documents is the indicator. Ask your HR department whether your plan is fully-insured or self-funded if you are unsure.
Federal and state laws explicitly prohibit insurance companies from retaliating against you for exercising your appeal rights. Specifically, your insurer cannot:
If you believe your insurer is retaliating, file a complaint with your state’s Department of Insurance and, for employer-sponsored plans, with the US Department of Labor’s Employee Benefits Security Administration (EBSA).
If your internal appeal and external review are both denied, or if your insurer is not following required procedures, you have additional escalation options.
| Option | Who It’s For | What It Can Do |
|---|---|---|
| State Insurance Commissioner Complaint | Fully-insured plans purchased in your state | Investigate insurer practices; mandate compliance; fine insurers for violations; assist in resolving disputes |
| Dept. of Labor — EBSA Complaint | ERISA employer-sponsored plans | Investigate plan administrator conduct; enforce ERISA fiduciary standards; compel compliance |
| CMS Complaint (healthcare.gov) | ACA Marketplace plans; Medicare | Investigate insurer compliance with ACA regulations; escalate to state regulators |
| State Attorney General | All state-regulated plans | Investigate potential consumer protection violations; pursue bad faith insurance practices |
| ERISA Federal Lawsuit | ERISA plans after exhausting appeals | Federal court review of benefit denial; can compel insurer to pay; attorney’s fees recoverable if you win |
| State Bad Faith Lawsuit | Fully-insured state-regulated plans | Sue for bad faith insurance practices; potential for punitive damages beyond the denied claim |
For most patients, state insurance commissioner complaints are the fastest and most accessible escalation path. Filing a formal complaint is free, requires no attorney, and puts the insurer on notice that regulatory oversight is involved.
AppealGen generates a professionally structured appeal letter in 10 minutes, tailored to your specific denial reason and clinical situation. Free to start — no account required.
Generate My Appeal Letter →Related guides: How to File an Insurance Appeal · Appeal Deadlines by State · Do You Need a Lawyer?