Your Rights When Your Health Insurance Denies a Claim

A denied health insurance claim can feel like a dead end. It isn't. Federal and state laws give you meaningful rights when an insurer says no — and using those rights effectively often changes the outcome.

Your Federal Rights Under the ACA

• Right to a clear denial reason: Your insurer must tell you in writing why your claim was denied and what criteria were used to make the decision.
• Right to internal appeal: You have the right to ask your insurer to review any denied claim. They must complete the review within federally mandated timeframes.
• Right to external review: If your internal appeal fails, you can request an independent external review. The reviewer's decision is binding on the insurer.
• Right to expedited review: For urgent medical situations, you can request a faster review — insurers must respond within 72 hours.
• Right to file a complaint: You can file a complaint with your state insurance department at any time.

What the No Surprises Act Adds

The No Surprises Act — effective January 2022 — added protections specifically against surprise out-of-network bills. If you were charged more than in-network rates for emergency care or services from out-of-network providers at in-network facilities, you have the right to dispute those charges through a federal independent dispute resolution process.

State Laws Add Additional Protections

Many states have insurance laws that go beyond federal minimums. Your state insurance department enforces these protections and can intervene when insurers violate them. Filing a complaint with your state insurance department is free and often prompts faster resolution than going through the insurer's own appeal process alone.

BenZen helps clients understand and exercise their coverage rights across ten states. Reach out if you need support navigating a denial.