Insurance Claim Denied: Your Step-by-Step Action Guide

A denial letter lands in your inbox or letterbox. Your first reaction might be shock, frustration, or resignation. But here's what matters: a denial is not a final answer. In most countries, most claim types, and most circumstances, you have the right to appeal — and people who do appeal win more often than they lose.

This guide gives you a concrete, step-by-step action plan for the first 48 hours — and beyond.

Step 1: Don't Accept It (Yet)

The first and most important step is mental: do not treat the denial as final. Insurance companies rely on the fact that most people give up at this point. Data across every major market shows that fewer than 1% of denied claimants actually file a formal appeal.

Put the denial letter aside, take a breath, and commit to understanding your options before deciding on any course of action.

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Step 2: Read the Denial Letter Carefully

Within the first 24 hours, read your denial letter with a focus on extracting the following information:

What specifically was denied? Is it the entire claim, or part of it? What dollar amount are you being refused?

What reason did the insurer give? Common denial reasons include: "not medically necessary," "pre-existing condition," "policy exclusion," "failure to obtain prior authorisation," "outside policy coverage," or "insufficient documentation." Write down the exact wording they used.

What appeal rights did they reference? Insurers in most countries are required to inform you of your appeal rights in the denial letter. Note any deadlines mentioned.

What is the deadline for appealing? This is critical. Missing an appeal deadline can forfeit your rights. Internal appeal deadlines typically range from 30 to 180 days depending on country and policy. Note the date immediately.

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Step 3: Locate and Read Your Policy

Within the first 24 hours, find your insurance policy document (it may be a physical document, in your insurer's online portal, or attached to a prior email). Locate:

• The section covering the type of claim you made
• Any exclusion clauses the insurer may be relying on
• The definition of key terms (like "medically necessary" or "pre-existing condition")
• The complaints and appeals procedure section

Read the relevant sections carefully. Policy language often contains ambiguities — and under the legal principle of contra proferentem, ambiguous terms in insurance contracts are generally interpreted in favour of the policyholder, not the insurer.

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Step 4: Identify the Regulator and Ombudsman in Your Country

Knowing who sits above your insurer is important from the start — both because it informs how you write your appeal letter and because you may need to escalate.

Country	Regulator	Free Dispute Body
Singapore	MAS	FIDReC
Australia	ASIC / APRA	AFCA
United Kingdom	FCA	FOS (Financial Ombudsman Service)
Malaysia	BNM	OFS
USA	State Insurance Commissioner	External Review (ACA/ERISA)
UAE	CBUAE	CBUAE Consumer Protection
Hong Kong	IA	ICB

Note the deadlines and claim value limits for the relevant free dispute body.

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Step 5: Gather Your Evidence

Before writing a single word of your appeal, compile your evidence:

• The original claim form and all supporting documents you submitted
• Medical records related to the claim (GP notes, specialist letters, test results)
• Any correspondence with the insurer (emails, letters, call records with dates and times)
• Your insurance certificate and policy schedule
• If it was a health claim: any doctor's letter or clinical guidelines supporting the medical necessity of your treatment

The strongest appeals are those where the evidence clearly and directly addresses the insurer's stated reason for denial. If the insurer said "not medically necessary" — your key evidence is a doctor's letter that specifically establishes medical necessity using the same language and standards your insurer uses.

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Step 6: Write Your Appeal Letter

Your appeal letter should be formal, structured, and specific. It must:

1. State clearly that you are formally appealing the denial of claim [reference] dated [date]
2. Address each ground for denial separately and specifically
3. Reference the evidence you're attaching and explain what each piece establishes
4. Cite any relevant regulations or policy terms that support your position
5. Make a specific demand (payment of full amount, or partial payment)
6. State your intention to escalate to the relevant ombudsman if not resolved within a set timeframe

The tone should be professional and factual — not emotional. Insurers respond to logic and regulatory accountability, not personal hardship (however real that hardship may be).

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Step 7: Submit and Track

Send your appeal by a method that creates a record: email with delivery confirmation, or recorded postal delivery. Keep a copy of everything you send.

Note the date you submitted your appeal, and the regulatory deadline by which the insurer must respond. Set a calendar reminder.

If the insurer acknowledges receipt, keep that confirmation. If they don't acknowledge within 5 business days, follow up in writing.

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Step 8: If the Internal Appeal Fails — Escalate

If your internal appeal is denied, or if the insurer fails to respond within their required timeframe, escalate to the free external dispute body in your country. In most jurisdictions this is free, independent, and in some cases binding on the insurer.

Do not be deterred by a second denial. External reviewers and ombudsman services consider cases afresh — they are not bound by the insurer's internal assessment. A meaningful proportion of cases that fail internally succeed at the ombudsman stage, often because the ombudsman applies regulatory standards more rigorously than the insurer's own team.

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Step 9: Know When to Consider Legal Advice

For most claims, the free dispute pathway (internal appeal + ombudsman) is sufficient. Consider specialist legal advice if:

• Your claim involves a large sum (particularly life insurance or long-term disability)
• You suspect bad faith conduct by the insurer
• Your claim has failed through the ombudsman process and you want to consider litigation
• You have an ERISA-governed employer plan in the USA (ERISA litigation is specialised)

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Quick Reference: First 48 Hours Checklist

• Read the denial letter and note the specific denial reason
• Note the appeal deadline
• Locate your policy and read the relevant sections
• Identify your country's regulator and free dispute body
• Start gathering evidence (especially any new medical evidence that addresses the denial reason)
• Draft your appeal letter or use ClaimBack to generate one

Ready to fight back? Generate your appeal letter free →