Insurance Appeal Failed — What to Do Next

Your internal insurance appeal was denied. That feels like the end — but it isn't. The internal appeal was just round one. Here's everything you can do after a failed internal appeal to keep fighting for the coverage you're owed.

Step 1: Request an Independent External Independent Review: Complete Guide" class="auto-link">External Review

External review is your most powerful next step. It's:

• Free — no cost to you
• Fast — decisions within 45 days (72 hours for expedited cases)
• Binding — your insurer must comply with the reviewer's decision on medical necessity

Under ACA §2719, most health insurance plans must offer external review. For ERISA plans, Department of Labor regulations also provide external review rights.

How to request it: Contact your insurer or your state's Department of Insurance. Tell them you've exhausted internal appeals and want to request independent external review. They must give you the information on how to proceed.

When to request expedited external review: If your condition could deteriorate while waiting for standard review (45 days), request expedited review — it must be completed within 72 hours.

Step 2: File a Complaint with Your State Insurance Commissioner

Even while pursuing external review, file a complaint with your state's Department of Insurance (DOI) simultaneously. This:

• Creates a formal regulatory record
• Often prompts the insurer to reconsider (insurers hate regulatory attention)
• Can reveal whether your insurer has a pattern of wrongful denials
• Is free and takes 15–20 minutes online

Find your state DOI at naic.org/state_web_map.htm.

Step 3: File a Department of Labor Complaint (for ERISA Plans)

If your plan is employer-sponsored, file a complaint with the US Department of Labor Employee Benefits Security Administration (EBSA) at dol.gov/agencies/ebsa/contact-ebsa. EBSA:

• Investigates ERISA violations
• Can require plans to comply with their own procedures
• Has broad authority to penalize plan administrators

Call the EBSA hotline: 1-866-444-3272

Step 4: Request a Review by Your State Insurance Ombudsman

Many states have a Health Insurance Consumer Assistance Program (HICAP) or Consumer Assistance Program (CAP) — federally funded, free consumer advocates who can help navigate your appeal. Find yours at healthcare.gov/have-job-based-coverage/appeal-a-coverage-decision/.

These advocates can:

• Review your denial letter and identify legal violations
• Help you prepare an external review request
• Advocate on your behalf with your insurer

Step 5: Consult an ERISA or Insurance Bad Faith Attorney

If your external review also fails, or if you have a large claim at stake, an attorney consultation is your next step.

ERISA attorneys typically work on contingency (no upfront fee) for large disability or health claims. They can:

• Sue your insurer in federal court under ERISA §502(a)(1)(B)
• Recover your denied benefits plus interest
• Potentially recover attorney's fees (ERISA allows fee recovery)

Insurance bad faith attorneys (for non-ERISA, individual policies) can sue for:

• Your denied benefits
• Consequential damages
• In some states, punitive damages (2–3× benefits for egregious conduct)
• Attorney's fees

The American Association for Justice (justice.org) and state bar referral services can connect you with attorneys experienced in insurance denials.

Step 6: Media and Patient Advocacy

For large or egregious denials, consider:

• State legislators — your state representative may be interested if your insurer has a pattern of denying a specific treatment
• Patient advocacy organizations — disease-specific organizations (cancer, MS, lupus, etc.) often have appeal support programs and can advocate publicly
• Medical professional societies — your physician's specialty society may have a patient advocacy arm

What If You Can't Afford to Wait?

While appeals are pending:

• Ask your provider about charity care — hospitals and clinics have financial assistance programs
• Manufacturer assistance programs — most brand-name drugs and some devices have patient assistance programs
• Clinical trials — if you're being denied an experimental treatment, you may qualify for a trial where it's free
• Ask your doctor about alternatives — sometimes a covered alternative exists

Fight Back With ClaimBack

ClaimBack helps you build the external review request, regulatory complaint package, and documentation needed to keep fighting after a failed internal appeal.

Continue your appeal with ClaimBack →

Related Reading

• Internal vs External Insurance Appeal
• Insurance Ombudsman Guide
• Common Reasons Insurance Claims Are Denied