Fighting Health Insurance Claim Denials: A Comprehensive Guide for 2025

If you've had a health insurance claim denied, you're not alone. Of the more than 5 billion payment claims filed each year, health insurance companies deny approximately 850 million of them, according to claim appeals company Claimable, which based its assessment on data from health-policy nonprofit KFF and the Centers for Medicare and Medicaid Services.

Key Takeaways

• Insurance companies deny a significant number of health insurance claims for millions of people each year, including individuals with disabilities, but many denials can be successfully appealed.
• Persistence, gathering supporting documentation, and seeking advocacy help, media involvement, or legal support can be crucial steps in challenging denied claims.
• Successful appeals not only help individuals but also can lead to broader policy changes and legal precedents that benefit others.
• Despite the high success rate of appeals (nearly 75%), less than 1% of patients actually challenge denied claims.

The Impact of Denied Health Insurance Claims

A denied claim can be frustrating if it is a onetime experience, but denied claims can be much more serious if you have a chronic condition or a lifelong disability. They are not only aggravating roadblocks for adults with disabilities but also parents of children with disabilities.

From necessary therapies to essential medical equipment, insurance companies often reject claims, leaving families scrambling for solutions. Many have fought back and won, setting precedents that benefit others in similar situations.

Surprisingly, less than 1 percent of patients appeal denied claims. Appealing can pay off though, as studies show that nearly three-quarters of claim appeals are granted.

Common Reasons for Insurance Claim Denials in 2025

Insurance companies frequently deny coverage for essential treatments by citing reasons such as:

• Procedures being deemed "experimental" or "not medically necessary"
• Strict policy exclusions
• Administrative errors or lack of proper documentation
• Network restrictions and out-of-network care
• Coding and billing errors

These denials can delay or completely prevent access to crucial medical care, creating financial and emotional strain. However, many individuals and advocacy groups have found ways to challenge these decisions successfully.

Success Stories: When Persistence Pays Off

When feeling discouraged about a denied claim, it can be helpful to know that others have been successful in their efforts to reverse denied claims. Here are some examples:

Judge Ruled in Favor of Autism Therapy

In 2021, a mother in California successfully sued United Behavioral Health, a division of UnitedHealthcare, after it denied coverage for applied behavior analysis (ABA) therapy for her son with autism. United Behavioral Health had specifically excluded ABA coverage, a widely recognized and scientifically validated therapeutic approach for autism considered a cornerstone treatment for individuals with the condition. The company's decision to exclude ABA coverage was seen as a direct violation of the rights of individuals with autism to receive necessary and appropriate medical care.

This landmark legal victory not only provided critical relief to the mother and her son but also had broader implications for the autism community. It set a precedent for future cases involving insurance coverage for ABA therapy and strengthened the rights of individuals with autism to access the care they need.

Quadriplegic Woman Secured a Specialized Power Wheelchair

Ali Ingersoll, a quadriplegic woman, faced initial denials from her insurance company for a specialized feature on her power wheelchair. After unsuccessfully appealing the decision to her insurance company, even after providing extensive documentation from medical professionals, Ingersoll contacted a local news station for help. After the station contacted the insurance company, coverage for the wheelchair feature Ingersoll needed to maintain her mobility and independence received approval.

Parents' Fight for Hearing Aids Coverage

Parents in Colorado challenged insurance policies that excluded hearing aids for their children. Through coordinated efforts, petitions, and legal action, they not only secured coverage for their children but also influenced state law. In 2008, Colorado passed legislation requiring insurers to cover pediatric hearing aids, benefiting families across the state.

Step-by-Step Guide to Fighting Insurance Claim Denials

If you or someone you know is dealing with an insurance denial, here are steps to challenge it effectively:

1. Review the Denial Letter Carefully

Begin by thoroughly examining the denial letter from your insurance company. Understanding the exact reason for rejection is crucial for crafting an effective appeal. Look for specific codes, terminology, or policy references that explain why your claim was denied.

In 2025, many insurance companies provide detailed digital explanations through their patient portals, which may contain more information than the physical letter. Be sure to check both sources.

2. Gather Supporting Documentation

Collect comprehensive evidence to support your appeal. This should include:

• Detailed letters from doctors, therapists, and medical professionals explaining why the treatment is medically necessary
• Relevant medical records and test results
• Scientific studies supporting the efficacy of the treatment
• Documentation of previous treatments and their outcomes
• Personal impact statements describing how the denial affects your health and quality of life

In 2025, digital health records make this process more streamlined, but you may need to request specific documentation from your healthcare providers.

3. File an Internal Appeal with the Insurer

Most insurance companies have a formal appeal process that must be followed:

• Submit your appeal within the specified timeframe (typically 30-180 days from denial)
• Include all supporting documentation gathered in step 2
• Reference specific insurance policy provisions that support your claim
• Request a specific reviewer with expertise in your medical condition
• Keep detailed records of all communications, including dates, names, and content of discussions

4. Seek Advocacy and Support

Don't fight alone. Organizations such as the Patient Advocate Foundation and the National Disability Rights Network can provide valuable assistance. In 2025, these organizations have expanded their digital support services, offering virtual consultations and assistance with appeal documentation.

Consider involving:

• Patient advocacy groups specific to your condition
• Insurance claim advocates
• Social workers with healthcare expertise
• Legal aid organizations specializing in healthcare access

5. Consider External Appeals and Legal Action

If internal appeals fail, you have additional options:

• Request an external review through your state's insurance department
• File a complaint with state or federal regulatory agencies
• Contact your state's insurance commissioner
• Consider media involvement to highlight your case
• Consult with an attorney specializing in insurance law or disability rights
• Explore class action possibilities if the denial affects many patients

The Broader Impact of Fighting Back

When individuals successfully challenge insurance denials, the benefits extend beyond their personal situation. These victories can:

• Establish legal precedents that help others with similar conditions
• Prompt policy changes within insurance companies
• Influence state and federal legislation regarding insurance coverage
• Raise public awareness about insurance practices and patient rights
• Create pathways for improved coverage for entire categories of treatment

Resources for Additional Support

To learn more about rights for individuals with disabilities, check out the Americans with Disabilities Act, which is part of the Civil Rights Division of the United States Department of Justice. You can learn more about filing an appeal through Claimable.

You can also contact an experienced special needs planning attorney in your area if you need more information about your specific situation and the legal options available to you. They can provide personalized guidance and support tailored to your family's needs.

In addition, you may find it helpful to talk with other professionals who specialize in working with people with disabilities and their families. This may include financial advisors, social workers, and educators. These experts can provide new ideas and resources of which you may not be aware and help you manage the various challenges of special needs planning. With their assistance, you can help ensure that your loved one with a disability gets the care and support they need now and in the future.

Conclusion: Persistence is Key

Though insurance denials can be disheartening, they are not always the final answer. Many individuals and families have successfully overturned coverage rejections through persistence, advocacy, and legal action. Their victories not only help them but also pave the way for better policies and protections for others facing similar struggles.

If you are dealing with an insurance denial, know that you are not alone — and that fighting back can make a difference. With the right approach and support, you can navigate the appeals process effectively and potentially secure the coverage you need and deserve.

This comprehensive guide was last updated on April 29, 2025, reflecting current health insurance appeal processes and best practices.