When Your Insurer Says No, Take Action

Despite your best efforts and a positive attitude, your insurer may still turn down a request for a specific treatment, a favorite doctor or other care. Don't take no for an answer if you feel strongly about your request -- at least not before exhausting all avenues of appeal.

  • First, try to negotiate yourself. Call the insurance plan representative or the managed care patient representative and explain your request and your reason for making it.
  • Call in the troops. Depending on how your insurance is administered, it may be possible to appeal and get a denial overturned just by working with your company's benefits manager or a representative in Human Resources.
  • Make a formal appeal. You can get substantial help doing this. The Patient Advocate Foundation, for instance, outlines the steps and includes sample letters in its booklet, "Your Guide To the Appeal Process," which can be downloaded from its Web site ( or requested by mail by writing the headquarters at 753 Thimble Shoals Blvd., Suite B, Newport News, VA 23606.

    Before writing the appeal letter, the guide suggests, be sure you understand your diagnosis and your coverage; get a copy of the denial letter and understand the basis on which the treatment or other care has been denied. According to provisions in the Federal Employee Retirement and Income Security Act (ERISA), a specific reason for the denial should be stated in the letter. If you don't understand specifics in the letter, call the plan and ask for a contact person; have the representative explain exactly why the care has been denied.

  • Call in more troops. In addition to your own appeal letter, you might also ask your physician to write a letter explaining why the treatment is crucial. To add even more weight to your case, consider adding studies from medical journals (your doctor may have these on hand) proving that the treatment or other care that is being denied is, in fact, effective.
  • Follow up promptly and properly. When you file the appeal, make sure you know the length of time it will take to get a response. (This information may be included in your insurance plan, or you may have to ask.) If you get a telephone call telling you the denial has been overturned, get it in writing before celebrating your victory.. If you get a second denial, you need to ask for that in writing too. You may be able to appeal it again, sometimes to an external review board of experts not involved with the insurance plan.
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