Fighting Health Insurance Claim Denials

Takeaways

• Insurance companies deny a significant number of health insurance claims for millions of people each year, including individuals with disabilities, but many denials can be successfully appealed.
• Persistence, gathering supporting documentation, and seeking advocacy help, media involvement, or legal support can be crucial steps in challenging denied claims.
• Successful appeals not only help individuals but also can lead to broader policy changes and legal precedents that benefit others.

If you’ve had a health insurance claim denied, you’re not alone. Of the more than 5 billion payment claims filed each year, health insurance companies deny about 850 million of them, according to claim appeals company Claimable, which based its assessment on data from health-policy nonprofit KFF and the Centers for Medicare and Medicaid Services.

A denied claim can be frustrating if it is a onetime experience, but denied claims can be much more serious if you have a chronic condition or a lifelong disability. They are not only aggravating roadblocks for adults with disabilities but also parents of children with disabilities.

From necessary therapies to essential medical equipment, insurance companies often reject claims, leaving families scrambling for solutions. Many have fought back and won, setting precedents that benefit others in similar situations.

Surprisingly, less than 1 percent of patients appeal denied claims. Appealing can pay off though, as studies show that nearly three-quarters of claim appeals are granted.

The Challenges of Insurance Claim Denials

Insurance companies frequently deny coverage for essential treatments by citing reasons such as:

• Procedures being deemed “experimental” or “not medically necessary”
• Strict policy exclusions
• Administrative errors or lack of proper documentation

These denials can delay or completely prevent access to crucial medical care, creating financial and emotional strain. However, many individuals and advocacy groups have found ways to challenge these decisions successfully.

Stories of Reversed Insurance Claim Denials

When feeling discouraged about a denied claim, it can be helpful to know that others have been successful in their efforts to reverse denied claims. Here are some examples:

Judge Ruled in Favor of Autism Therapy

In 2021, a mother in California successfully sued United Behavioral Health, a division of UnitedHealthcare, after it denied coverage for applied behavior analysis (ABA) therapy for her son with autism. United Behavioral Health had specifically excluded ABA coverage, a widely recognized and scientifically validated therapeutic approach for autism considered a cornerstone treatment for individuals with the condition. The company’s decision to exclude ABA coverage was seen as a direct violation of the rights of individuals with autism to receive necessary and appropriate medical care.

This landmark legal victory not only provided critical relief to the mother and her son but also had broader implications for the autism community. It set a precedent for future cases involving insurance coverage for ABA therapy and strengthened the rights of individuals with autism to access the care they need.

Quadriplegic Woman Secured a Specialized Power Wheelchair

Ali Ingersoll, a quadriplegic woman, faced initial denials from her insurance company for a specialized feature on her power wheelchair. After unsuccessfully appealing the decision to her insurance company, even after providing extensive documentation from medical professionals, Ingersoll contacted a local news station for help. After the station contacted the insurance company, coverage for the wheelchair feature Ingersoll needed to maintain her mobility and independence received approval.

Parents’ Fight for Hearing Aids Coverage

Parents in Colorado challenged insurance policies that excluded hearing aids for their children. Through coordinated efforts, petitions, and legal action, they not only secured coverage for their children but also influenced state law. In 2008, Colorado passed legislation requiring insurers to cover pediatric hearing aids, benefiting families across the state.

How to Fight Back Against Denials

If you or someone you know is dealing with an insurance denial, here are steps to challenge it effectively:

• Review the denial letter carefully. Understand the exact reason for rejection.
• Gather supporting documentation. Obtain letters from doctors, therapists, and medical professionals explaining why the treatment is necessary.
• File an internal appeal with the insurer. Most insurance companies have an appeal process; be sure to meet the necessary deadlines.
• Seek legal or advocacy support. Organizations such as the Patient Advocate Foundation and the National Disability Rights Network may be able to provide assistance.
• Consider external appeals and legal action. If internal appeals fail, some states allow for external reviews or lawsuits against insurers.

Learn More About Reversing Insurance Denials

Though insurance denials can be disheartening, they are not always the final answer. Many individuals and families have successfully overturned coverage rejections through persistence, advocacy, and legal action. Their victories not only help them but also pave the way for better policies and protections for others facing similar struggles. If you are dealing with an insurance denial, know that you are not alone — and that fighting back can make a difference.

To learn more about rights for individuals with disabilities, check out the Americans with Disabilities Act, which is part of the Civil Rights Division of the United States Department of Justice. You can learn more about filing an appeal through Claimable.

You can also contact an experienced special needs planning attorney in your area if you need more information about your specific situation and the legal options available to you. They can provide personalized guidance and support tailored to your family’s needs.

In addition, you may find it helpful to talk with other professionals who specialize in working with people with disabilities and their families. This may include financial advisors, social workers, and educators. These experts can provide new ideas and resources of which you may not be aware and help you manage the various challenges of special needs planning. With their assistance, you can help ensure that your loved one with a disability gets the care and support they need now and in the future.

For further reading about health insurance and rights for individuals with disabilities, check out the following articles:

• Managing Medical Bills and Insurance Paperwork: 7 Tips for Maximizing Reimbursement
• Justices Skeptical of Arguments to Overturn Health Care Law, Which Protects People with Disabilities
• Disability Community Continues Fight for Access to Home Care
• Lawsuit Threatens Section 504 of the Rehabilitation Act
• Mental Health Parity: What It Is and Why It Still Matters