My Insurance Claim Was Denied — What Are My Rights?

When your insurance claim is denied, most people accept the decision. They shouldn't. Every insurance denial triggers a set of legal rights that are powerful, free to exercise, and frequently lead to reversal. Here's everything you're entitled to — and how to use it.

Your Right to Know Why (And See the Evidence)

Your insurer cannot simply say "no." Under federal and state law, they must tell you:

• The specific reason for the denial (not just "not covered")
• The policy provision they're relying on
• The clinical criteria used, if it's a medical claim
• How to appeal and the deadline to do so
• Your right to request all documents they used to make the decision

Under ERISA (for employer health or disability plans), you can request every document, record, and piece of information relevant to your claim — for free. Your insurer must provide it.

Your Right to Appeal

Every health insurance plan regulated by the ACA — and every ERISA-governed plan — must offer at least one level of internal appeal. You typically have 30–180 days from the denial to file.

For ACA-compliant health plans:

• First internal appeal: insurer must decide within 30 days (urgent care: 72 hours)
• External Independent Review: Complete Guide" class="auto-link">External review: available after internal appeal is exhausted

For ERISA disability/health plans:

• First internal appeal: 180-day deadline to file
• Insurer must decide within 45–90 days
• External review rights vary by plan

For individual policies (non-ERISA):

• State law governs — typically 30–60 days to appeal
• State Department of Insurance oversight applies

Your Right to External Independent Review

After your internal appeal is denied, you have the right to an independent external review — a completely separate review by an organization not affiliated with your insurer:

• Free to you
• Binding on your insurer (they must comply with the result for medical necessity questions)
• Fast — 45 days standard, 72 hours expedited
• Available for: medical necessity denials, rescissions, benefit coverage disputes

Request external review through your insurer or your state's Department of Insurance.

Your Right to Expedited Review for Urgent Situations

If the standard timeline would "seriously jeopardize your life, health, or ability to regain maximum function," you have the right to expedited review:

• Internal appeal: decision within 72 hours (24 hours for concurrent care denials)
• External review: decision within 72 hours

Tell your insurer: "I am requesting an expedited appeal because my treating physician has determined that the standard timeline would seriously jeopardize my health."

Your Right to File State Regulatory Complaints

Your state's Department of Insurance (DOI) regulates insurer conduct. You have the right to file a complaint at any time — free — if you believe your insurer:

• Denied your claim unfairly
• Failed to respond within required timeframes
• Misrepresented your policy
• Engaged in unfair claims settlement practices

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

Most states require insurers to respond to DOI complaints within 15–30 days. A DOI complaint doesn't guarantee reversal but creates regulatory pressure and a formal record.

Your Right to File with the Department of Labor (ERISA Plans)

For employer-sponsored health or disability plans, the Department of Labor Employee Benefits Security Administration (EBSA) enforces ERISA. You can file a complaint at dol.gov/agencies/ebsa.

EBSA can:

• Investigate ERISA violations
• Require plans to comply with their own procedures
• Penalize plan administrators for procedural violations

Your Right to Sue Under ERISA

After exhausting internal and external appeals, ERISA claimants can file a lawsuit in federal district court under ERISA §502(a)(1)(B) to recover benefits. Key points:

• There's no jury — a federal judge decides based on the administrative record
• Attorney's fees can be recovered if you win
• The standard of review depends on whether the plan grants the administrator discretion

Your Right to Sue for Bad Faith (Non-ERISA Plans)

For individual insurance policies (not ERISA-governed), most states allow you to sue your insurer for bad faith if they:

• Denied your claim without reasonable investigation
• Misrepresented facts or policy provisions
• Failed to pay undisputed amounts promptly

Bad faith remedies can include your policy benefits plus extracontractual damages — and in some states, punitive damages.

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ClaimBack generates a professional appeal letter in 3 minutes — citing your specific rights, applicable law, and the evidence framework your insurer must address. 40–83% of properly filed appeals succeed.

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Related Reading

• How to Write an Insurance Appeal Letter
• Internal vs External Insurance Appeal
• Insurance Ombudsman Guide