Insurance Claims and Appeals
All disabled people have the right to healthcare without financial ruin. Insurance systems are designed to be complex—understanding how to navigate claims and appeals is a survival skill, not a personal failing. This page centers disabled people’s expertise and is informed by disabled-led organizing globally.
Why This Matters
Section titled “Why This Matters”Insurance denial is not a mistake. It is a business strategy.
Disabled people face higher rates of claim denials, longer appeals processes, and more administrative burden than non-disabled people. When you’re already managing symptoms, appointments, and daily survival, fighting insurance becomes another job—unpaid and exhausting.
This page exists because:
- Denials are often reversed on appeal, but most people don’t appeal
- The process is intentionally opaque
- Disabled people share strategies that work, and those strategies deserve documentation
- You shouldn’t have to figure this out alone while sick
Understanding Insurance Denials
Section titled “Understanding Insurance Denials”Why Claims Get Denied
Section titled “Why Claims Get Denied”Insurance companies deny claims for many reasons, some legitimate and many not:
- Administrative errors: Wrong codes, missing information, claim filed to wrong address
- Prior authorization not obtained: Required approval wasn’t requested before treatment
- “Not medically necessary”: Insurer disagrees with your doctor’s judgment
- Out-of-network provider: Care received outside approved network
- Experimental or investigational: Treatment labeled as unproven
- Pre-existing condition exclusions: Limited in some countries, still exists in others
- Benefit limits reached: Annual or lifetime caps on specific services
- Timely filing deadline missed: Claim submitted too late
What disabled people know: Many denials are automated. A human may never have reviewed your claim. The first denial is often just the first step, not the final answer.
The Denial Letter
Section titled “The Denial Letter”Every denial must include:
- The specific reason for denial
- The policy provision or clinical guideline used
- How to appeal
- Deadlines for appeal
If your denial letter is vague or missing information, that itself may be grounds for complaint.
Where Are You?
Section titled “Where Are You?”Insurance systems vary dramatically by country. Navigate to your location:
United States
Section titled “United States”Types of Insurance and Appeal Rights
Section titled “Types of Insurance and Appeal Rights”Employer-Sponsored and ACA Marketplace Plans
These plans must follow Affordable Care Act rules:
- Internal appeal (reviewed by someone not involved in original denial)
- External review by independent organization
- Expedited review for urgent situations (72 hours)
- You can request your complete claim file
Medicare
Appeals process has five levels:
- Redetermination by Medicare Administrative Contractor
- Reconsideration by Qualified Independent Contractor
- Administrative Law Judge hearing
- Medicare Appeals Council review
- Federal court
Medicaid
Each state has its own appeals process. You typically have the right to:
- Fair hearing before denial takes effect
- Continue receiving services during appeal (if you appeal quickly)
- Bring an advocate or representative
ERISA Plans (Most Employer Plans)
These follow federal ERISA rules:
- Must provide written denial with specific reasons
- At least one full internal appeal
- 180 days to file appeal (check your plan—some are shorter)
- Can sue in federal court after exhausting appeals
Step-by-Step: Filing a U.S. Insurance Appeal
Section titled “Step-by-Step: Filing a U.S. Insurance Appeal”Step 1: Get your denial in writing
Call and request the written denial if you haven’t received it. Document the call (date, time, representative name, reference number).
Step 2: Understand the deadline
Most plans give 180 days for internal appeal, but some give only 60. Mark the deadline immediately.
Step 3: Request your complete claim file
You have the right to every document the insurer used to make their decision. Request this in writing. This often reveals the actual reason for denial.
Step 4: Get a letter from your doctor
Your provider should write a letter explaining:
- Your diagnosis and medical history
- Why this treatment is medically necessary for you specifically
- What happens without this treatment
- Why alternatives won’t work or haven’t worked
- Citations to medical literature if relevant
Step 5: Write your appeal letter
Include:
- Your name, policy number, claim number
- Date of denial
- Specific reason you’re appealing
- Supporting evidence (doctor’s letter, medical records, research)
- Request for expedited review if urgent
Step 6: Submit and document everything
- Send by certified mail or fax with confirmation
- Keep copies of everything
- Note dates and reference numbers
Step 7: If internal appeal is denied, request external review
External reviewers overturn insurance company decisions roughly 40-50% of the time, depending on the state and type of denial.
U.S. Resources
Section titled “U.S. Resources”Disability-Led Organizations
- Health Care for the Homeless Council: Works on access issues affecting disabled homeless people
- Autistic Self Advocacy Network: Fights insurance denials for autism-related services
- Disability Rights Advocates: Litigates systemic insurance discrimination
State Resources
- Your state insurance commissioner handles complaints
- State Health Insurance Assistance Programs (SHIP) help with Medicare
- Patient advocates at hospitals can help navigate appeals
Legal Help
- Legal aid organizations often help with insurance appeals
- Some law schools have health law clinics
- The Patient Advocate Foundation offers case management
Who’s Organizing
Section titled “Who’s Organizing”Disabled people are fighting insurance discrimination through:
- Documenting denial patterns across conditions
- Pushing for mental health parity enforcement
- Fighting prior authorization delays
- Challenging “fail first” requirements that force people to try cheaper treatments before accessing what works
Canada
Section titled “Canada”Provincial Health Insurance
Section titled “Provincial Health Insurance”Medically necessary hospital and physician services are covered by provincial plans. However, many disability-related needs fall outside this:
- Prescription drugs (varies by province)
- Assistive devices
- Mental health services
- Rehabilitation
Each province has its own appeal process for coverage decisions.
Private Insurance Appeals
Section titled “Private Insurance Appeals”If you have employer-sponsored or private insurance:
- Review your policy for appeal procedures
- Request written denial with reasons
- Submit appeal in writing with medical documentation
- Many provinces have ombudsman services for insurance complaints
Canadian Resources
Section titled “Canadian Resources”- Provincial health ombudsman offices: Handle complaints about coverage decisions
- ARCH Disability Law Centre (Ontario): Provides legal information
- Disability Alliance BC: Advocacy and information on benefits
United Kingdom
Section titled “United Kingdom”NHS Appeals
Section titled “NHS Appeals”The NHS doesn’t typically deny care in the same way private insurance does, but access issues exist:
- Postcode lottery for certain treatments
- Individual Funding Requests for treatments not routinely commissioned
- Continuing Healthcare assessments
Individual Funding Requests (IFR)
If treatment isn’t routinely available, you can request an IFR. This requires showing your case is exceptional. Decisions can be appealed through:
- The NHS body that made the decision
- NHS complaints procedure
- Parliamentary and Health Service Ombudsman
Continuing Healthcare (CHC)
Section titled “Continuing Healthcare (CHC)”If you’re denied NHS Continuing Healthcare funding:
- Request a written decision with reasons
- Ask for a local resolution meeting
- Request Independent Review Panel
- Complain to Parliamentary and Health Service Ombudsman
UK Resources
Section titled “UK Resources”- Disability Rights UK: Information on healthcare rights
- Citizens Advice: Help with NHS complaints
- POhWER: NHS complaints advocacy in England
Australia
Section titled “Australia”Medicare and PBS Appeals
Section titled “Medicare and PBS Appeals”Medicare covers medical services; the Pharmaceutical Benefits Scheme (PBS) covers medications. For PBS issues:
- Contact Services Australia
- Request review of decisions
- Appeal to Administrative Appeals Tribunal if needed
NDIS Appeals
Section titled “NDIS Appeals”National Disability Insurance Scheme decisions can be appealed:
- Internal review by NDIS
- External review by Administrative Appeals Tribunal
What disabled Australians know: Document everything from your first NDIS contact. Decisions often contradict each other, and having records matters.
Private Health Insurance
Section titled “Private Health Insurance”The Private Health Insurance Ombudsman handles complaints about private insurers.
Australian Resources
Section titled “Australian Resources”- People with Disability Australia: Advocacy organization
- Disability Advocacy Network Australia: Connects to local advocates
- Health Care Consumers’ Association: Patient advocacy
European Union
Section titled “European Union”Insurance systems vary by country, but some common principles:
Cross-Border Healthcare Directive
EU citizens can seek healthcare in other member states and seek reimbursement. Denials of reimbursement can be appealed through national systems.
Country-Specific Systems
- Germany: Statutory health insurance (Krankenkasse) decisions can be appealed to social courts
- France: CPAM decisions can be challenged through Commission de Recours Amiable, then social security tribunal
- Netherlands: Health insurer decisions can be appealed internally, then to the Healthcare Insurance Disputes Committee
Other Countries
Section titled “Other Countries”General Principles That Apply Everywhere
Section titled “General Principles That Apply Everywhere”Regardless of your country’s specific system:
- Get denials in writing: Verbal denials are harder to fight
- Understand deadlines: Most systems have time limits for appeals
- Document everything: Dates, names, reference numbers
- Get medical support: Provider letters matter everywhere
- Find local advocates: Disability organizations often know the system
- Connect with others: Other disabled people with your condition may have fought the same battles
Finding Help in Your Country
Section titled “Finding Help in Your Country”- Search for disability rights organizations in your country
- Patient organizations for your specific condition often have insurance navigation resources
- Legal aid organizations may help with healthcare access
- UN CRPD monitoring bodies track healthcare access issues
Strategies That Work
Section titled “Strategies That Work”What Disabled People Have Learned
Section titled “What Disabled People Have Learned”On the initial claim:
- Use correct diagnostic and procedure codes—one wrong digit can cause denial
- Submit complete documentation upfront
- Keep copies of everything before sending
- Follow up to confirm receipt
On appeals:
- Appeals often succeed—don’t give up after one denial
- The appeal reviewer is usually different from the initial reviewer
- New evidence can be submitted at appeal
- A doctor’s direct call to the insurer’s medical director sometimes helps
- Peer-to-peer review (your doctor talking to their doctor) is sometimes available
On persistence:
- External review overturns many denials
- State insurance commissioners can intervene
- Media attention has resolved some cases
- Class action lawsuits have changed insurer policies
Red Flags in Denial Letters
Section titled “Red Flags in Denial Letters”Watch for:
- Vague language like “not meeting criteria” without specifying which criteria
- Denial based on guidelines that don’t match your condition
- Reviewer credentials that don’t match your medical specialty
- Identical denial language across multiple claims (suggests automated denial)
When to Get Help
Section titled “When to Get Help”Consider getting an advocate or attorney if:
- The denial involves a large amount or ongoing treatment
- You’ve exhausted internal appeals
- The denial seems to misunderstand your condition
- You’re too sick to manage the process yourself
- The deadline is approaching and you can’t manage it alone
Intersectionality and Insurance
Section titled “Intersectionality and Insurance”Insurance barriers compound other forms of discrimination:
Race and Insurance
- Black patients face higher denial rates for certain procedures
- Prior authorization requirements can encode racial bias in medical guidelines
- Language barriers affect appeal success
Poverty and Insurance
- Appeal processes assume time, energy, and resources
- Missing work for phone calls and appointments adds financial strain
- “Fail first” requirements delay effective treatment while people suffer
Mental Health and Insurance
- Mental health claims historically denied at higher rates
- Parity laws exist but enforcement is weak
- Psychiatric history can be used to dismiss physical complaints
Rural Access
- Fewer in-network providers means more out-of-network denials
- Telehealth coverage varies
- Travel costs for appeals processes add burden
Related Pages
Section titled “Related Pages”- Healthcare Rights
- Accessible Healthcare
- Proving You’re Disabled
- Benefit Denials and Appeals
- Medical Dismissal
This page centers disabled people’s expertise and is informed by disabled-led organizing globally. Insurance systems are designed to be difficult—surviving them is not a personal achievement, but a collective struggle. For questions or to suggest additions, see How to Contribute.
Contribute to This Page
Section titled “Contribute to This Page”Have lived experience or expertise that could strengthen this page? We especially welcome perspectives on models not well represented here, including those from the Global South and Indigenous communities.
This page centers disabled people’s expertise and is informed by disabled-led organizing globally. For questions or to suggest additions, see How to Contribute.