At the Shanley Insurance Agency, we believe in putting our clients first—because we work for you, not the insurance companies. As an independent life and health insurance agency in Upstate SC for over 25 years, we don’t push any one companies plan options. Instead, we shop, compare, and find the best coverage at the lowest costs to meet our clients unique needs. Insurance is not a one size that fits all!
With 35+ years of experience, unfortunately I have seen first hand how frustrating and overwhelming it can be when a health insurance company denies necessary procedures or surgery your doctor says is needed. But here’s what most people don’t realize—a denial is not the final word! You have rights, and you have options.
In this post, I’ll walk you through step-by-step actions you can take if your insurance company denies your claim—so you’re never left without the coverage you deserve.
1. Understand Why Your Claim Was Denied
The first step is to determine exactly why your insurance company denied the claim. The denial reason will be included in an Explanation of Benefits (EOB) or a denial letter your insurance company is required to provide for you to review.
Common Reasons for Denial:
The treatment is not deemed medically necessary. (your company believes the procedure isn’t essential).
The service is considered experimental or investigational. (for newer treatments).
You used an out-of-network provider (your plan requires in-network care).
A referral or prior authorization was never sent in to the company or is missing (some services require approval first).
A coding or paperwork error (incorrect billing codes, missing documentation).
What You Need to Do:
Call your insurance company to get more details about ;why there was a denial.
Ask your doctor to confirm if they submitted all required paperwork correctly.
Request a copy of your health insurance policy to review your coverages.
Check Your Insurance Plan’s Coverage & Benefits Before appealing, check whether the denied procedure is excluded from your health insurance plan.
Steps to Take:
Read through your insurance policy document (available online or by request).
Look for any policy exclusions (services your plan explicitly doesn’t cover).
If unsure, contact your insurance agent or HR benefits administrator for clarification.
*Pro Tip: Sometimes insurance companies deny valid claims by mistake—so double-check their reasoning*
Request a Formal Appeal
If you believe the denial was unfair, you have the legal right to appeal. Most insurance companies offer two types of appeals:
Internal Appeal (First Level Appeal)
This is a formal request for your insurance company to reconsider its decision.
How to File an Internal Appeal:
Submit a written letter explaining why the service is medically necessary.
Include a letter from your doctor supporting your case.
Attach medical records, test results, or studies proving the need for treatment.
Deadline: Typically 30-180 days after receiving the denial notice.
Processing Time: Usually 30 days for non-urgent cases and 72 hours for urgent cases.
External Review (Second Level Appeal)
If the internal appeal is denied, you can request an external review, where an independent third party legally decides whether the denial was justified.
Where to File an External Appeal:
Your State Insurance Department
The U.S. Department of Health & Human Services (HHS) for federal plans
Processing Time: Typically 45 days for standard reviews and 72 hours for urgent cases.
*Pro Tip: Keep copies of all documents, including your appeal request and any responses from the insurer*
Get Your Doctor Involved in the Appeal Process
Doctors and healthcare providers understand how to fight insurance denials—so don’t do this alone!
Ask your doctor to:
✔ Write a strong letter explaining why the treatment is necessary.
✔ Provide supporting medical records and test results.
✔ Submit additional paperwork if needed.
Why This Works: A doctor’s expert opinion adds weight to your appeal and increases the chances of approval.
5️. Seek Help from Consumer Assistance & Advocacy Programs
If you feel overwhelmed, you don’t have to fight alone!
Where to Get Help:
✔ State Health Insurance Consumer Assistance Programs (CAPs) – Many states have free services to help you file appeals.
✔ Your State Department of Insurance – Can step in if an insurance company is violating policy rules.
✔ A Patient Advocate – Some hospitals provide free advocates who can help you appeal denials.
✔ Legal Help – If your insurer is acting unfairly, consider speaking to a health insurance attorney.
*Pro Tip: Some patient advocacy programs are free or low-cost—check your state resources*
6️. File a Complaint if Your Appeal is Unfairly Denied
If your internal and external appeals are denied unfairly, you can take it further by filing a formal complaint.
Where to File a Complaint:
✔ State Department of Insurance (handles consumer protection cases).
✔ Your employer’s benefits department (if the policy is employer-sponsored).
✔ The U.S. Department of Labor (for self-funded employer health plans).
Why This Works:
Insurance companies don’t want regulatory investigations, so filing a complaint can sometimes push them to reconsider a denial. I can tell you from personal experience when you mention to an insurance company that your going to file a complaint with your "State Department of Insurance". Insurance companies do not want the Department of Insurance involved. In my case the claim was originally denied that morning, then I filed a complaint with the SC Department of Insurance that afternoon. The company had to call me the next morning before 8am to tell me my claim was approved.
Final Thoughts: Don’t Take ‘NO’ for an Answer!
A denied health insurance claim is "NOT" the final decision—you have rights, and you can fight back! Many claims are reversed when appealed properly, so don’t assume you have to give up and pay out of pocket.
Let's Review What You Need to Do If Your Claim Was Denied:
Review your health insurance policy carefully.
File an internal appeal with medical records & doctor support.
Request an external review if necessary.
Get help from state programs, legal experts, or patient advocates.
File a complaint with your State's Department of Insurance if you believe your denial was unfair.
If you have any questions or need expert advice on navigating your health insurance coverage? Contact the Shanley Insurance Agency today—we’re here to help you understand your options and protect your healthcare rights!