FAQ: What to Do When Your Insurance Appeal Is Denied Again
Insurance denied your appeal? Don't give up. Learn what to do after a second denial — external review, ombudsman, regulatory complaints, and legal action — and why many claims that fail internally succeed on external review.
FAQ: What to Do When Your Insurance Appeal Is Denied Again
Your appeal was denied. Again. It can feel like there's nowhere left to turn — but a second denial from your insurer's internal appeal process is often not the end. In most countries, independent external review and regulatory escalation provide powerful, genuinely independent routes to overturn even a double-denied insurance claim.
Here's exactly what to do when your insurance appeal is denied for the second time.
Q: If my insurer denied my appeal, is that final?
No. Your insurer's internal appeal decision is not the final word on your claim. After exhausting internal appeals, you have access to independent review mechanisms that are not controlled by the insurer:
United States:
- External review by an Independent Review Organisation (IRO): Binding on the insurer, conducted by truly independent clinical reviewers. This is available after your insurer's final adverse determination.
- State Department of Insurance complaint: Regulatory investigation by your state's insurance commissioner.
- Litigation: Suing the insurer in state court (for non-ERISA plans) or federal court (for ERISA plans).
United Kingdom:
- Financial Ombudsman Service (FOS): Independent adjudication — FOS decisions are binding on the insurer.
- Courts: Legal action for breach of contract or FCA violations.
Australia:
- Private Health Insurance Ombudsman (PHIO): For health insurance disputes.
- Australian Financial Complaints Authority (AFCA): Binding decisions for financial services complaints.
- Courts: Civil action.
Singapore:
- FIDREC: Independent adjudication (binding on the insurer up to the jurisdictional limit).
- LIA Claims Conciliation Panel (for life/CI disputes).
- Singapore courts.
Malaysia:
- Ombudsman for Financial Services (OFS): Independent adjudication binding on the insurer.
- BNM BNMLINK: Regulatory escalation.
- Malaysian courts.
Q: Why do external reviews overturn denials that internal appeals didn't?
External reviewers — whether IROs in the US, the FOS in the UK, FIDREC in Singapore, or AFCA in Australia — are genuinely independent of the insurer. They apply national clinical standards and legal standards, not the insurer's internal criteria (which may be more restrictive).
Studies and data consistently show that external review overturns a significant proportion of internal appeal denials:
- US IRO data: Studies show that 30–60% of external reviews result in decisions for the consumer, depending on the type of claim and insurer
- UK FOS data: The FOS upholds approximately 35–40% of insurance complaints overall (varying by insurer and product)
- FIDREC (Singapore): A meaningful proportion of adjudicated disputes resolve in the consumer's favour
The most important reason for these reversal rates: external reviewers are not financially incentivised to deny claims. Internal insurer reviewers work within systems that, directly or indirectly, create cost-containment incentives. External reviewers do not.
Q: What's different about the external review or ombudsman process?
Independent reviewers: IROs, the FOS, FIDREC, and OFS are independent organisations with no financial relationship with the insurer. Their reviewers are not employed by the insurer and have no incentive to deny your claim.
National clinical standards: External reviewers apply recognised clinical guidelines (e.g., NIH guidelines, NCCN guidelines, NICE guidelines, AHA/ACC guidelines, ASAM criteria) rather than the insurer's internal policies. If the insurer's internal criteria are more restrictive than national standards, this can be decisive.
Legal standards: External reviewers also consider whether the denial violated applicable law (MHPAEA, ACA, NMHPA, state mandates). Internal reviewers may ignore legal violations that external reviewers will catch.
Consumer-friendly process: External review processes are designed to be accessible to consumers without requiring legal representation. You present your evidence; the reviewer decides impartially.
Q: What should I do differently for external review compared to my internal appeal?
Stronger specialist documentation: If your internal appeal relied on a primary care physician letter, your external review submission should include a specialist's letter from a board-certified physician in the relevant specialty.
Direct response to the insurer's criteria: Request the insurer's specific clinical criteria used to deny your claim. Your external review submission should quote those criteria verbatim and address each one with specific evidence.
Peer-reviewed clinical literature: Attach peer-reviewed journal articles, clinical guidelines from professional bodies, and systematic reviews supporting your treatment. External reviewers are clinical professionals who can engage with this literature.
New evidence not in the internal appeal record: Some external review processes allow submission of new evidence not included in the internal appeal. Where permitted, include any additional medical records, test results, or expert opinions obtained after your internal appeal.
For the FOS (UK) — evidence of unfair treatment: The FOS applies a "fair and reasonable" standard, not just a legal one. Evidence that the insurer treated you unfairly — even if technically within policy terms — can support an FOS finding in your favour.
Q: How do I request external review in the US?
- After your insurer's final internal appeal decision, contact the insurer and request external review initiation (instructions should be in the appeal denial letter)
- Alternatively, contact your state's Department of Insurance to initiate the process (for fully insured plans)
- File within the required deadline — typically 4 months from the final internal denial (check your state's specific rule)
- Submit your supporting documentation to the IRO when requested
- The IRO will review and issue a binding decision within 45 days (standard) or 72 hours (expedited)
Q: What if external review also fails?
If external review or the ombudsman also fails (or if the amount at stake is above the ombudsman's jurisdiction), your remaining options are:
Legal action:
- Consult an attorney specialising in insurance disputes (bad faith, ERISA, contract law)
- Many operate on contingency for qualifying cases
- Litigation is time-consuming and expensive but may be appropriate for large claims
Additional regulatory complaints:
- File complaints with multiple regulatory bodies simultaneously (state DOI, Department of Labor, HHS, etc.)
- Regulatory pressure can sometimes resolve disputes even after external review
Political escalation (US):
- Contact your state's Insurance Commissioner's office
- Contact your congressional representative's constituent services office — congressional inquiries to federal agencies (like CMS for Medicare) can sometimes produce faster resolution
Media and advocacy:
- For particularly egregious denials involving life-threatening conditions, patient advocacy organisations and journalists covering healthcare can amplify your case
- Public pressure has reversed notable insurance denials
Q: Is it worth continuing to fight?
That depends on:
- The amount at stake (large amounts justify more effort)
- The strength of your medical evidence (strong evidence justifies continuing)
- Your energy and resources (fighting an appeal takes time and emotional energy)
- The legal strength of your position (some denials are clearer-cut violations than others)
But statistically: external review succeeds for a meaningful proportion of internally-denied claims. If you have strong medical evidence and your treating physician believes the denied treatment was necessary, the external reviewer — a genuinely independent clinical professional — is quite likely to agree.
The answer to "is it worth it?" is usually yes — especially if the denied service was medically necessary and the denial appears to violate clinical standards or applicable law.
Conclusion
A second internal denial is not the end. External review, the Financial Ombudsman, FIDREC, OFS, and AFCA all provide genuinely independent routes that overturn a significant proportion of internally denied claims. Build a stronger case for external review — more specialist evidence, direct rebuttal of the insurer's criteria, peer-reviewed literature — and don't give up until you've exhausted all independent review options. Use ClaimBack at claimback.app to generate a comprehensive appeal letter for your external review or ombudsman submission.
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