Health Insurance Denied Your Claim? Follow This Simple Appeal Strategy

A health insurance claim denial can arrive without warning. One letter, one email or one notification can suddenly leave patients facing unexpected medical bills or delayed treatment. For many, the first reaction is frustration. Others assume the insurer's decision is final and reluctantly pay the costs themselves. Yet evidence suggests that is often the wrong approach.

According to research by Miranda Yaver, assistant professor of health policy and management at the University of Pittsburgh and author of Coverage Denied, claim denials are more common than many people realise. More importantly, people who formally challenge a rejection often succeed. Understanding why claims are denied and knowing how to appeal could make the difference between paying thousands out of pocket and having essential treatment covered.

Claim Denials Are More Common Than Many Expect

Yaver began researching health insurance claim denials after experiencing repeated rejections herself despite having health insurance while working as a research fellow. Speaking to Kiplinger Personal Finance, she said she found the process confusing and time-consuming, even with her academic background.

That experience prompted her to investigate how widespread the issue had become. In 2022, Yaver surveyed 1,340 Americans with different types of healthcare cover. Her research found that 36 per cent had experienced at least one health insurance coverage denial. Nearly 60 per cent of those respondents had faced multiple denials. The findings suggest that rejected claims are not isolated incidents but a routine challenge for many patients.

Why Insurers Reject Claims

According to Yaver, insurers deny claims for a range of reasons, many of which have little to do with whether a patient genuinely needs treatment. Common reasons include a judgement that care is not medically necessary, a procedure being classified as experimental, billing or coding errors, or the absence of required prior authorisation.

Prior authorisation has become one of the biggest sources of disputes. Many insurers require doctors to obtain approval before certain treatments or medicines are covered. Yaver told Kiplinger that insurers use prior authorisation to control costs and reduce unnecessary treatment. However, she questioned whether the system consistently achieves those goals, arguing that it can instead delay necessary care for patients.

She also noted that doctors reviewing requests may not always have expertise in the patient's medical condition. In one case she highlighted, a patient seeking treatment for a rare hearing disorder had their request reviewed by a gynaecologist.

AI Is Changing Claims Decisions

Health insurers are increasingly using artificial intelligence to process claims.Yaver acknowledged that AI could improve efficiency in some areas but warned that the technology still has significant limitations. She told Kiplinger that AI systems may fail to understand the full medical context of individual patients and that errors could have serious consequences when healthcare decisions are involved. Yaver also pointed to the limited regulatory oversight surrounding AI use in health insurance and said the technology is not yet advanced enough to replace careful human judgement.

The Appeal Process Can Deliver Results

Despite the number of denied claims, relatively few people formally challenge the decision. Yaver cited survey data showing that as few as one per cent of patients appeal a denial.

Those who do often achieve positive outcomes. Her research found that 52 per cent of respondents who appealed successfully overturned their insurer's decision. She also highlighted findings from a separate 2024 survey showing that 80.7 per cent of Medicare Advantage beneficiaries who appealed a prior authorisation denial received either full or partial approval. The figures suggest that an initial rejection does not necessarily represent the final outcome.

How to Appeal a Denied Claim

Yaver recommends first asking your doctor or healthcare provider to appeal directly with the insurer. If that is unsuccessful, patients should begin the insurer's formal appeals process.

The denial letter should be read carefully because it explains why the claim was rejected, outlines the appeals procedure and provides the submission deadline. Patients should respond directly to the insurer's reasons for rejecting the claim. Supporting evidence may include updated medical records, letters from treating specialists or new clinical research relevant to the patient's condition.

Keeping copies of all correspondence, medical documents, and telephone conversations can also help if the dispute continues. If the insurer rejects the internal appeal, many policies allow patients to request an independent external review, where another organisation examines whether the denial was justified.

Persistence Can Make the Difference

Appealing a denied claim can feel exhausting, particularly for people already coping with illness. However, Yaver argues that many patients abandon the process too early because they assume the insurer's first decision cannot be challenged. Her research suggests otherwise.

While no appeal is guaranteed to succeed, the available evidence indicates that patients who understand the process, provide strong medical evidence, and meet appeal deadlines have a meaningful chance of overturning a denial and securing the healthcare cover they expected.