What to Do When Your Health Insurance Claim is Rejected (Step-by-Step)

You submitted your health insurance claim. You waited. And then you got the letter: Claim Denied.

Maybe it was for a surgery, a hospital stay, expensive medication, or ongoing treatment. Whatever it was, you're now facing a bill you expected insurance to cover — and you're wondering what to do next.

Here's the truth: A claim rejection is almost never the end of the story. This guide shows you exactly what to do, step by step, when your health insurance claim is rejected.

Step 1: Don't Panic (Seriously)

First, take a breath. A rejected claim feels like a financial disaster, but here's what you need to know:

• 70-80% of appealed claims are eventually paid when the appeal is done properly
• Less than 1% of people actually appeal — which means insurers reject claims knowing most won't fight back
• You have rights — and in most countries, strong consumer protections

The initial denial is often just the insurer's first move. They're testing whether you'll accept it.

Don't.

Step 2: Read the Denial Letter Carefully

Your denial letter (sometimes called an "Explanation of Benefits" or EOB) contains critical information:

Look for:

• The specific reason — Pre-existing condition? Not medically necessary? Out of network? Missing paperwork?
• Policy sections cited — Exact clauses or exclusions they're referencing
• The amount — How much they're refusing to pay
• Appeal deadlines — You usually have 30-180 days to appeal (varies by country/policy)
• Instructions for appealing — How to submit your appeal

Don't just skim it. Read every word. The denial reason determines your entire appeal strategy.

Step 3: Call Your Insurance Company

Before you do anything else, pick up the phone. Call the number on your denial letter.

Questions to ask:

• "Can you explain in plain English why this was denied?"
• "What evidence would I need to provide for this to be reconsidered?"
• "What is the exact deadline for filing an appeal?"
• "Can I submit additional medical documentation?"
• "Who made the decision to deny this claim?" (sometimes it's a nurse or medical reviewer you can request info about)

Take notes. Write down:

• Date and time of call
• Name of the person you spoke with
• Reference number for the call
• Everything they tell you

This creates a paper trail if you need to escalate later.

Step 4: Contact Your Doctor

Your doctor is your most powerful ally. They understand the medical side and can provide evidence the insurer can't ignore.

Ask your doctor to provide:

• A letter explaining why the treatment was medically necessary
• Medical records supporting the treatment decision
• Evidence that less expensive alternatives weren't appropriate
• Any relevant medical guidelines or studies

Example doctor letter excerpt:

"The patient's condition required immediate surgical intervention due to [specific medical reasons]. Conservative treatment with physical therapy was not appropriate because [medical explanation]. This procedure is considered standard of care for this diagnosis according to [medical guideline/organization]."

This carries far more weight than anything you can say as a patient.

Step 5: Gather Your Evidence

You're building a case. Collect:

Medical documentation:

• All medical records related to the treatment
• Test results, scans, lab work
• Prescription history
• Doctor's notes and recommendations

Financial documentation:

• All receipts and bills
• Proof of payment
• Records of any partial payments the insurer did make

Communication records:

• The denial letter (obviously)
• Any previous communication with the insurer
• Policy documents and coverage summaries
• Notes from your phone call (Step 3)

Policy proof:

• The exact section of your policy showing the treatment should be covered
• Any pre-authorization approvals you received

Organize everything chronologically. Make copies of everything.

Step 6: Understand Common Denial Reasons and How to Fight Them

If denied for "pre-existing condition":

• Get your doctor to state when the condition actually began
• Check your policy's definition of "pre-existing" (often time-limited)
• Prove you didn't know about the condition when you bought coverage

If denied for "not medically necessary":

• Doctor's letter is critical here
• Include medical guidelines supporting the treatment
• Show why cheaper alternatives weren't appropriate

If denied for "out of network":

• Was it an emergency? (Most policies cover emergency out-of-network care)
• Check if the provider was listed as in-network when you sought care
• Some countries require insurers to pay for out-of-network emergency care

If denied for "missing documentation":

• Resubmit everything with proof you submitted it originally
• Include a checklist showing you've provided everything required

Step 7: Write Your Formal Appeal Letter

This is the most important document. It needs to be professional, specific, and evidence-based.

Structure:

1. Header: Your policy number, claim number, date
2. Opening: "I am writing to formally appeal the denial of my claim..."
3. Summary of facts: What treatment, when, how much
4. Why the denial is wrong: Reference specific policy language, medical evidence, regulations
5. What you're asking for: "I request that this claim be reviewed and paid in full."
6. Deadline: "I request a response within [14-21] days."
7. Signature

Tone: Firm but professional. Not angry. Not pleading. Factual.

Step 8: Submit Your Appeal (With Proof)

How to submit:

• Follow the instructions in your denial letter exactly
• Send via certified mail or registered post (get proof of delivery)
• Or submit online if available — take screenshots of confirmation
• Keep copies of everything you send

What to include:

• Your appeal letter
• All supporting medical documentation
• Doctor's letter
• Copies of relevant policy sections
• Any other evidence

Step 9: Follow Up

Don't just send your appeal and wait passively.

After 2 weeks: Call to confirm they received it After 4 weeks: Call for a status update If they need more info: Provide it immediately

Most insurers are required to respond within 30-60 days, but some drag it out. Be persistent.

Step 10: If Internal Appeal Fails — Go External

If your insurer upholds the denial, you're not done. Most countries have external review processes:

United States:

• External review through your state's insurance department
• Or federal external review for ACA plans

United Kingdom:

• Financial Ombudsman Service (free, independent)

Singapore:

• FIDReC (Financial Industry Disputes Resolution Centre)
• CCRP for medical disputes

Australia:

• AFCA (Australian Financial Complaints Authority)

UAE:

• Insurance Authority complaints process

These external bodies are free, independent, and rule in favor of consumers in the majority of properly documented cases.

How Long Does This Take?

• Internal appeal: 2-6 weeks
• External review: 6-12 weeks
• Legal action: 6-24 months (usually not necessary)

Most cases resolve at the internal appeal stage if you present strong evidence.

Common Mistakes to Avoid

❌ Waiting too long — Appeal deadlines are real ❌ Accepting the denial without appealing — This is what insurers count on ❌ Writing an emotional letter — Stick to facts and policy language ❌ Not including medical evidence — Doctor's support is critical ❌ Giving up after the first denial — That's just round one

Get Professional Help

If writing a formal appeal feels overwhelming, you don't have to do it alone. ClaimBack analyses your denial reason and generates a professional appeal letter tailored to your country's insurance regulations.

It includes:

• Analysis of your denial reason and appeal strength
• A complete, personalised appeal letter ready to send
• Step-by-step instructions for your specific country
• Document checklist

It takes 3 minutes and gives you everything you need to fight back effectively.

Real Success Stories

Singapore: S$18,000 cancer treatment denied as "experimental." Appeal included oncologist letter citing international medical guidelines. Paid in full after FIDReC review.

Australia: $8,500 knee surgery denied as "not necessary." Doctor's letter showed conservative treatment had failed for 8 months. Claim approved on first appeal.

UK: £12,000 private hospital stay denied as "should have used NHS." Policy actually allowed private care with GP referral (which patient had). Paid after Financial Ombudsman review.

US: $34,000 emergency surgery denied as "out of network." No Surprises Act applied. Insurer paid after patient cited federal law in appeal.

The Bottom Line

When your health insurance claim is rejected:

1. Read the denial carefully
2. Call the insurer for clarity
3. Get your doctor's support
4. Gather all evidence
5. Write a professional appeal
6. Submit with proof
7. Follow up persistently
8. Escalate if needed

Most importantly: Don't give up. The insurance company is counting on you to accept the denial quietly. By appealing properly, you join the small minority who actually get their claims paid.

Your denial isn't the end. It's just the beginning of getting what you're owed.