Consumers have rights to appeal claim denials

Editor's note: During National Consumer Protection Week, OIC is offering tips to help protect insurance consumers in Washington.

Sometimes, insurance companies deny claims for reasons that vary as widely as there are claims. Here is some information about insurance claim denials and your appeal rights.

Health insurance

Most health plans are required to comply with a very specific appeal process. However, this requirement doesn’t apply to some health plans, such as Medicare or Apple Health (Medicaid) plans.

Other types of insurance, such as long-term care or disability insurance, are required to provide an appeal process but can create their own process.

If you want to file an appeal with your health plan, contact them and ask: “What do I need to do to file an appeal?” After that, you’ll need to collect materials that support your appeal, such as:

• The health problems that can or will arise if the company doesn’t pay for this treatment, plus an estimate of the cost of treating those problems.
• Any medical journal articles or studies that show the treatment’s effectiveness.
• Letters from your doctors describing why you need this treatment.

After you send your appeal materials to the health plan, be persistent. Most people don’t win at the first level of appeal, but the odds of winning increase as you reach higher levels of appeals. The chance of winning is highest when your health plan appeal reaches the final level, called an “Independent Review Organization.”

For more tips, please visit the appeals section of our website.

Property and casualty insurance

With property and casualty insurance—such as homeowner, renter and auto insurance—consumers generally can use the appraisal provision of their auto or home policy or the arbitration provision for personal injury protection (PIP) and under- or uninsured motorist (UIM) claims on auto policies. Appraisal provisions are used for disputes of claim value, and arbitration provisions are generally used when the application or availability of coverage is being questioned.

More information

• You can file a complaint against your insurance company, regardless of what type of policy you have, with OIC’s consumer advocates.
• For Medicare questions, you can contact a Statewide Health Insurance Benefits Advisor (SHIBA).
• People must apply for Apple Health through Washington Healthplanfinder. Consumers who are enrolled in Apple Health must contact the Health Care Authority with appeals and follow-up issues.