We buy insurance policies to protect our finances against devastating outcomes. But what happens when you have a reasonable claim, and the insurance company denies it? Denial rates vary by type of insurance, but a recent KFF Survey of Consumer Experiences found that roughly 1 in 5 insured adults had a claim denied in the previous year. Here’s why claims are denied, what to do when insurance claims get denied, and six tips for writing an appeal letter.
Although your insurance claim may be reasonable and necessary, that doesn’t mean that it will be approved by your insurance provider. There are many reasons why insurance claims get denied, including some that seem reasonable and others that are frustrating.
6 Common Reasons Why Your Insurance Claim May Be Denied
- Lapsed coverage or missed payments. Missing a payment may cancel coverage, resulting in automatic denial. Even if you bring your policy current, it is possible that claims during that lapse in coverage may be denied.
- Incomplete or incorrect documentation. Denials often happen because policyholders did not adequately document their claim.
- Policy exclusions. Your policy might not cover the specific type of damage or incident.
- Missed filing deadlines. Filing too late can automatically result in a denial.
- Disputes over necessity or liability. Insurers may challenge whether the loss qualifies under their coverage definitions.
- Pre-existing conditions. Policies typically exclude conditions that were present before the insurance coverage was in effect.
In addition to these common reasons, some claims are mistakenly denied due to clerical errors. The data may be entered incorrectly, a system error may occur during review, or other issues may happen. If your claim is denied, don’t accept that as the final decision.
Step-by-Step: How to Fight a Denied Claim
When you feel that your denied claim should have been approved, you need to fight back. When I worked in the insurance industry, several of my clients had claims denied. However, their claims were ultimately approved after we identified the cause and addressed the issue.
Follow these steps to appeal the denial and get your insurance company to cover the bills.
Carefully Review the Denial Letter
Upon receiving the denial letter, carefully review it for the reasons why the claim was denied. Denial letters often have generic, boilerplate language, but your insurer must provide a specific reason why they won’t cover your claim.
Request a Detailed Explanation of Denial
If you don’t understand the reasons for denial, or the letter wasn’t specific enough, contact your insurer for a more detailed explanation. You may be able to get answers to simple questions over the phone. However, for your appeal, it is often better to get their response in writing. This eliminates hearsay and ensures that you don’t misrepresent what customer service said when talking with family, friends, or your attorney about your situation.
Review Your Policy
Read through your policy to understand what your policy covers, any dollar limits on coverage, and any exclusions that apply. Compare the denial letter with the policy language to determine whether your claim should be covered. If you disagree with the insurer’s interpretation of your claim versus coverage, consider filing an appeal.
Gather Your Documentation
Collect all documentation related to your claim. This documentation should include medical records, repair estimates, receipts, photos, witness statements, and other relevant information. Maintain a detailed log of all communication with your insurer. This list should include phone calls, emails, and in-person conversations. Keep track of names, dates, and what was discussed, along with copies of emails, letters, and documents sent or received.
File a Formal Internal Appeal
Once you’ve established cause to appeal, write a formal letter appealing the insurance company’s decision. In this letter, you should reference specific policy terms that back up your claim and attach all supporting documentation.
Act Quickly to Preserve Your Rights
File your appeal right away to protect your rights. Missing the deadline could end your appeal, even if you have a solid reason and documentation to back up your claim. Appeal deadlines vary by insurance type and company.
For example, HealthCare.gov states that you must file an internal appeal for health plan decisions within 180 days of receiving notice that your claim was denied.
Be Persistent With Follow-up
Insurers must also act timely in reviewing your appeal. For example, medical appeals must be completed within 30 days if you haven’t received service yet or 60 days for services already completed.
However, you don’t have to wait that long to receive a final decision. Be the squeaky wheel, and be persistent. Follow up regularly to get status updates and ensure that your appeal is moving through the process, rather than being ignored on the corner of someone’s desk.
Request an Independent Review
If the internal appeal doesn’t go your way, you have the right to take your appeal to an independent third party for review. This review is handled by someone outside of the insurance company, who gets the final say on whether to pay the claim.
In an urgent medical situation, the final decision by an external reviewer must be made as quickly as your condition requires or up to four business days, whichever is sooner.
Escalate to Regulators or the Courts
When an insurer acts in bad faith, you can file a complaint with your state’s Department of Insurance or take them to court. Most insurance companies would rather settle a covered claim than face a public lawsuit that could be a public relations nightmare for them.
Tips for Writing a Strong Appeal Letter
These tips provide a guide for writing your appeal letter to give you the best chance of receiving approval for your denied claim.
- Lead with the claim number, policy number, and denial date.
- Write short, factual statements. Do include emotional wording or your opinions.
- Cite specific policy language that supports your claim.
- Include an explanation of your reconsideration request. Provide supporting documentation, such as a copy of the claim, professional recommendations, and copies of earlier communication.
- Send via certified mail or a tracked delivery method. Insurance companies sometimes claim they never received appeals.
- Keep copies of everything you submit.
What to Do Next: Tips for Fighting Denials by Insurance Type
If your insurance claim has been denied, how to appeal and what to include in your appeal letter may vary based on the type of claim and the type of insurance that covers it. Here are a few of the most common forms of insurance and tips for fighting a denial of claim.
Homeowners Insurance
Contact your adjuster about their decision and ask them to make a home visit. Consider getting a third-party appraiser, contractor, or real estate agent to back up the value of your home and the reasonableness of your claim.
Auto Insurance
Common ways to back up your appeal are a police report, witness statements, accident scene photos, mechanic estimates or invoices, and medical bills.
When I was a young driver, I was in a few accidents. While none of them were my fault, I had to prove that my driving wasn’t the cause. By combining the findings within police reports and photos of the accident location, I was able to prove that the other driver was at fault, so their insurance would pay the claims instead of mine.
Medical / Health / Dental Insurance
Health insurance denials are often a dispute about the interpretation of plan details rather than whether your claims are medically necessary. In some cases, claims are denied because the doctor used the wrong billing code or didn’t get prior authorization. Ask your doctor to write a letter explaining why they chose that billing code or to consider resubmitting using a different code that would get approved.
Life Insurance
Before submitting your appeal, ask the insurer for the full claim file and compare the denial against specific policy exclusions. Many states have incontestability clauses that limit the insurer’s ability to deny a claim based on misrepresentations on the application if the policy has been in force for more than two years.
One of my clients passed away shortly after the two-year anniversary of his policy. He wasn’t completely truthful on his application, which could have resulted in the insurer denying the claim completely or paying out a reduced death benefit. However, because it was beyond the two-year contestability period, the insurer had to pay out the full death benefit to his family.
Disability Insurance
Many disability claims are denied due to insufficient evidence supporting the claim. Include written opinions from your treating physicians, applicable medical records, and (if applicable) evidence from your employer supporting your inability to perform your job. For example, a job description that requires workers be able to lift heavy objects.
Pet Insurance
Claims are often denied due to pre-existing conditions with pets. Gather vet records, treatment notes, and a letter from your veterinarian supporting why your pet’s condition started after your coverage began.
Consider Switching Insurance Providers
When all else fails, it may be time to move on from your current insurance policy. People often shop policies to lower their premiums, but how an insurer handles claims should also be part of the evaluation. If your current insurer won’t cover your claims, moving to another provider may yield better results in the future. Just be aware of any policy language that may exclude pre-existing conditions if you have ongoing claims.
The Bottom Line About Insurance Claim Denials
Getting denied for an insurance claim isn’t the end. Insurance companies often deny claims due to clerical errors, lapses in coverage, or incomplete information. By appealing this decision in a timely manner, you give yourself the best chance of receiving the care you’re entitled to. Review the denial letter, gather supporting information, and write your appeal letter in a factual manner without including emotion or opinion. If the appeal is denied, you can request an external review, contact your state’s insurance commissioner, or file a lawsuit to continue the fight.
Sources
- KFF, Consumer Survey Highlights Problems with Denied Health Insurance Claims. Published September 29, 2023.
- HealthCare.gov, Appealing a health plan decision. Accessed April 29, 2026.
- Patient Advocate Foundation, Where to Start if Insurance Has Denied Your Service and Will Not Pay. Accessed April 29, 2026.
- National Association of Insurance Commissioners, Health Insurance Claim Denied? How to Appeal the Denial. Published August 17, 2020.
- Ethos Life Insurance Services,Life Insurance Contestability Period. Accessed April 29, 2026.
The information provided on this website is for general informational and educational purposes only and should not be considered legal, financial, or insurance advice. While we strive to keep content accurate and up to date, insurance laws, policies, and regulations can vary by state and may change over time.
Nothing on this site constitutes professional advice or a recommendation of any specific insurance product, provider, or strategy. You should consult with a licensed insurance agent, financial advisor, or legal professional regarding your individual situation before making any decisions.
