Ask a Lawyer: How Should You Handle Denied Insurance Claims in Connecticut

You have the right to appeal insurance claim denials in Connecticut if your provider declines to pay a valid health, auto, worker’s compensation, or homeowner’s claim. Review the four steps to take in this situation, then consult an experienced insurance dispute attorney in East Hartford, CT to guide you through the process of seeking appropriate compensation.

4 Key Steps After Insurance Claim Denial: Advice From Your East Hartford, CT Insurance Dispute Attorney

1. Review the Denial Notice Carefully

Before appealing an insurance denial, you need to understand the exact reason for the decision. You can find the necessary information in the Explanation of Benefits document included with the denial letter. Common causes of insurance denial include:

• Missing records or supporting documents
• Errors in the claim like a typo in your Social Security number
• Lack of preauthorization where required by your plan
• Claims that fall outside your covered benefits
• Lack of medical necessity for the requested service

You can easily correct and resubmit some denied claims, while other issues require further appeal. If you don’t understand the Explanation of Benefits, call your insurance provider. Document the date and time of the call, the name of the person who helps you, and the answers they provide to your questions.

2. Follow the Appeal Instructions for Your Policy

Each insurance company has its own process to appeal a denial. The insurer performs an internal investigation and either issues a new decision or upholds the original denial. They must respond to your appeal request within 72 hours for urgently needed care, 30 days for pending treatment, or 60 days for treatment you already received.

3. Request an External Review

If the provider denies your claim again, you may be able to request escalation to receive an independent review from a neutral third-party investigator. In this case, the investigator’s decision is legally binding. You can also request an escalated external review immediately if the claim denial could seriously jeopardize your health or ability to function within the 30-to-60-day review window.

External review is available in Connecticut only if you received a treatment that was supposed to be covered by your plan but the insurance provider either:

• Rescinded coverage
• Claimed you were ineligible for the treatment
• Denied an investigational or experimental treatment
• Claimed the treatment was not medically necessary

4. Gather the Necessary Materials

You will need to contact your healthcare provider to obtain medical records and other official documents to support your appeal. For example, physicians often write letters to insurance companies to support the medical necessity of a denied treatment.

Your appeal request should also include a copy of the denial letter, a copy of your health insurance card, and your personal notes about how the medical issue affects your life. You can also include medical literature about the efficacy of the requested treatment if it was denied as experimental or investigational.

An experienced attorney can support you through the insurance claim appeals process. Contact Adler Law Group, LLC Attorneys at Law in East Hartford, CT today for assistance and guidance. 

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