If a disability, health or life insurance claim is denied, gathering information, staying within deadlines and communicating with all relevant parties to gather necessary information is essential in order to overturn the decision.

When a dispute over any insurance benefits arises, being told “no” is not the final word. If the coverage at issue is provided by your employer, the likelihood is that it is governed by the federal ERISA (Employee Retirement Income Security Act) law. Insurance claims can be denied for a wide range of reasons, including missing paperwork or allegedly failing to meet policy requirements. Under ERISA, everyone has a right to appeal a denied claim, which means that all insurance providers have to allow the process and provide a full and fair review of the benefit denial. Anyone going through the appeal process needs to take the steps in the best way possible to increase the chances of positive results.

Gather information

Because there are so many reasons an insurance claim could be denied, it is vital that the filer first find out why his or her claim was rejected. The best way to do so is to request a copy of the complete insurance claim file. Under ERISA, you are entitled to that documentation without charge.

Once the basis for the denial is understood, more information will usually have to be assembled in order to convince the insurance company that a mistake has been made. Although some of that information may readily be available, you may need to undergo additional testing or examination to obtain the proof you need. Some examples of additional documentation that is often required include the following:

  • Records and reports from treating doctors that explain in detail why you are disabled, why a medical procedure is necessary, or why, from a medical perspective, coverage is appropriate;
  • A corrected medical treatment code
  • A vocational rehabilitation consultant’s report (disability claims)
  • A post-mortem or pathologist’s report (death claims)

Armed with the right documents, a claimant will have a better chance of being approved.

Follow deadlines

There are strict deadlines for various claims that need to be met. A failure to meet a required deadline can be fatal to proceeding with a meritorious claim. Deadlines for appeals can be as short as only a few days or as long as 180 days depending on the nature of the claim.

Communicate with all relevant parties

Following a benefit denial, there may be a need for communicating with the insurance company claim representative or with other relevant parties. It is important to keep all lines of communication open at all times in order to prevent a misunderstanding that could have disastrous consequences.

Consult with a knowledgeable professional

Insurance is complicated. Appealing from adverse insurance claims is as complicated as it gets. Do not tackle an appeal alone. Make sure you have an experienced advocate on your side who has the know-how and a proven track record of success. The lawyers at DeBofsky Sherman Casciari Reynolds P.C. have handled thousands of claim appeals and they can assist you as well.

Related Articles

Why do health insurers deny claims?

When you are ill and a doctor recommends a course of treatment, you naturally assume that your health insurer will reimburse the cost.  That is not always the case, though, and it is not uncommon for benefits to be denied, especially if the costs are high.  Examples...

Mental health coverage required under 2008 parity act

Increasing awareness of federal requirements for equal health insurance coverage of mental and physical conditions has led to a spate of litigation relating to health insurance denials. In Christine S. v. Blue Cross Blue Shield of New Mexico, 2019 WL 6974772 (D. Utah,...