Maternity and Childbirth Insurance Claim Denied: How to Appeal

Maternity and Childbirth Insurance Claim Denied: How to Appeal

Maternity care — including prenatal visits, labour and delivery, postpartum care, and newborn care — is one of the most fundamental areas of healthcare. Denying or limiting maternity insurance coverage has significant health consequences for mothers and newborns. Yet maternity insurance disputes are surprisingly common, ranging from denials of specific prenatal tests to disputes about hospital stay duration after delivery.

If your insurer has denied a maternity-related claim, you have powerful legal rights to challenge it.

The Law: Maternity Coverage Rights

In the United States:

The Pregnancy Discrimination Act (PDA): Employers with 15+ employees cannot discriminate against pregnant employees in any aspect of employment, including health insurance benefits. Group health plans must cover pregnancy-related conditions to the same extent as other medical conditions.

The ACA (Affordable Care Act): Maternity and newborn care is one of the 10 Essential Health Benefits that all ACA-compliant individual and small group health plans must cover. This means:

• Prenatal care must be covered
• Labour and delivery must be covered
• Newborn care must be covered
• Postpartum care must be covered

The Newborns' and Mothers' Health Protection Act (NMHPA): Federal law requires health plans to cover:

• A minimum 48-hour hospital stay after vaginal delivery
• A minimum 96-hour hospital stay after caesarean section
• Plans cannot incentivise earlier discharge or penalise providers for longer stays when medically necessary

State maternity mandates: Many states have additional requirements beyond federal law, including coverage for:

• Fertility treatment leading to pregnancy (in mandate states)
• Midwifery and homebirth services
• Doula services (in some states)
• Postpartum depression screening and treatment
• Breastfeeding support and equipment

In the United Kingdom: The NHS provides comprehensive maternity care at no cost. For private maternity care disputes, the Financial Ombudsman Service (FOS) adjudicates complaints against private health insurers.

In Australia: Under Medicare, maternity care is covered. Private health insurance covers private hospital maternity care. PHIO and AFCA handle disputes.

In Singapore: MediShield Life and Integrated Shield Plans cover hospitalisation for normal delivery and C-sections. Complications of pregnancy are generally covered as medical conditions.

Common Maternity Claim Denial Reasons

Waiting period disputes: Many private health insurance plans have 10–12 month waiting periods before pregnancy-related coverage commences. Disputes arise about:

• When the waiting period actually started
• Whether the pregnancy predated the coverage start
• Whether maternity coverage from a prior insurer transfers

ACA Essential Health Benefit disputes: For ACA-compliant plans:

• Denials of covered prenatal services
• Denials of covered labour and delivery services
• Denials that violate the NMHPA minimum stay requirements

C-section vs. vaginal delivery coverage disputes: Some plans cover vaginal delivery more generously than C-sections. However, a medically necessary C-section must be covered as medical care.

NICU (neonatal intensive care) denials:

• NICU care denials are among the most emotionally difficult and legally challengeable maternity insurance disputes
• NICU care for a premature or ill newborn is medically necessary by definition
• Newborns have their own insurance rights separate from the mother's

Home birth and birth centre denials: Some plans cover hospital birth but deny claims for licensed midwife-attended home births or accredited birth centre deliveries.

Postpartum care denials:

• Postpartum depression screening and treatment denials
• Lactation consultant visit denials
• Breastfeeding equipment (breast pump) denials (required under ACA for preventive services)

Prenatal screening denials:

• Genetic testing (NIPT, amniocentesis) denied as "not medically necessary"
• Additional ultrasounds denied beyond the standard schedule

Step-by-Step: Appealing a Maternity Claim Denial

Step 1: Identify the Specific Denial

Is this a:

• Waiting period dispute?
• ACA Essential Health Benefit violation?
• NMHPA minimum stay violation?
• Specific service exclusion?
• Medical necessity dispute (prenatal test, C-section, NICU)?

Step 2: Know Your Federal Protections

For US maternity appeals, the most powerful arguments are:

• ACA Essential Health Benefits: Any denial of covered maternity care from an ACA-compliant plan
• NMHPA: Any denial of the minimum 48/96-hour hospital stay after birth
• MHPAEA: For postpartum depression and mental health related maternity care
• Preventive Services (ACA Section 2713): Breastfeeding support and breast pumps must be covered without cost-sharing

Step 3: Gather Documentation

For prenatal test denials:

• Your OB-GYN's letter recommending the test and explaining medical necessity (maternal age, family history, abnormal screening results)
• Evidence the test falls within standard prenatal care guidelines (ACOG guidelines)

For NICU denials:

• Neonatologist's letter documenting the medical necessity of NICU care
• NICU admission criteria and records
• Documentation of the newborn's diagnosis and clinical status

For C-section denials:

• Your OB-GYN's documentation of the medical indication for C-section
• Intrapartum records showing the clinical basis for the decision

For NMHPA violations:

• Documentation that you were discharged before the legally required minimum stay
• Evidence that the discharge was insurer-driven (insurer denied continued coverage) rather than medically indicated

Step 4: Submit Your Appeal

Your appeal should:

• Cite the applicable federal law (NMHPA, ACA, PDA) or state mandate
• Include physician documentation supporting the medical necessity of denied services
• Specifically state that the denial appears to violate a federal or state legal requirement
• Request a specific remedy (pay the claim, reverse the denial)

Step 5: Request External Review

After exhausting internal appeals, request external review. For maternity denials involving federal law violations (NMHPA, ACA), external reviewers can apply these laws independently of insurer-internal criteria.

Step 6: File Regulatory Complaints

US:

• Department of Labor (ERISA plans): For NMHPA and ACA violations
• State Department of Insurance: For fully insured plan violations
• HHS Office of Civil Rights: For pregnancy discrimination violations

UK: Financial Ombudsman Service Australia: PHIO, AFCA Singapore: FIDREC, MAS

Breastfeeding and Breast Pump Coverage

Under the ACA, health insurers must cover:

• Comprehensive lactation support (breastfeeding counselling and support by a trained provider)
• Breastfeeding equipment (breast pump) — manual or electric

These must be covered without cost-sharing (no copays, deductibles, or coinsurance) as preventive services. Denials of breast pump coverage or lactation consultant visits under ACA-compliant plans are likely illegal. Appeal citing ACA Section 2713 and the HRSA Women's Preventive Services Guidelines.

Conclusion

Maternity care denials — particularly those that violate the NMHPA, ACA Essential Health Benefits requirements, or preventive services mandates — are among the most legally clear-cut insurance violations. Know your federal rights, cite them explicitly in your appeal, file regulatory complaints if your rights are being violated, and escalate to external review. Use ClaimBack at claimback.app to generate a professional appeal letter for your maternity insurance claim denial.

---

Related Reading:

• How to Write an Insurance Demand Letter
• How to Write a Second Insurance Appeal Letter
• Can You Sue Your Insurance Company?
• Insurance Bad Faith: Your Rights When an Insurer Wrongfully Denies