A denied health insurance claim can be both frustrating and scary—especially if it involves treatment for a pre-existing condition. Whether it’s diabetes, heart disease, cancer, or another chronic illness, denial can feel like a personal setback. But here’s the good news: you don’t have to accept that “no” as final. In many cases, you can appeal and overturn the decision.
This article walks you through how to appeal a denied health insurance claim related to a pre-existing condition, including your legal rights, what documentation you need, and tips to strengthen your case.
Understanding the Basics: What Is a Pre-Existing Condition?
A pre-existing condition is any health issue that you had before your health insurance policy started. Common examples include asthma, arthritis, depression, and high blood pressure.
Thanks to the Affordable Care Act (ACA), health insurance companies cannot deny coverage or charge more because of pre-existing conditions in most individual and employer-based plans. However, claim denials still happen due to:
- Administrative errors
- Incorrect coding
- Claims deemed “not medically necessary”
- Misinterpretation of policy terms
Step 1: Review the Denial Letter Carefully
Start by reading the Explanation of Benefits (EOB) or the denial letter from your insurance company. This document should explain:
- Why the claim was denied
- The specific policy provision they’re citing
- Your right to appeal and the deadline to do so
Common reasons include:
- “The treatment was not medically necessary”
- “The service is excluded from your plan”
- “The condition is pre-existing and not covered”
Understanding the reason is crucial—it determines how you should build your case.
Step 2: Know Your Legal Rights
The ACA protects people with pre-existing conditions under most insurance plans. Insurers cannot deny coverage based on your health history. However, if you’re on:
- Short-term plans, travel insurance, or certain grandfathered plans, these rules may not apply.
- Medicare Advantage or Medigap policies may have unique rules for pre-existing conditions, though restrictions have eased in recent years.
Check your policy type and whether it complies with ACA regulations.
Step 3: Contact Your Insurance Provider
Call your insurer’s customer service or claims department and ask for clarification. Questions to ask:
- What specific documentation do you need to overturn the denial?
- Was there a billing or coding issue?
- Can the claim be reprocessed?
Sometimes, simple errors—like the wrong billing code or missing referral—can be corrected without a formal appeal.
Tip: Document the conversation. Write down the date, representative’s name, and what they told you.
Step 4: Start the Internal Appeals Process
If your claim isn’t resolved informally, you can file a formal appeal, also known as an internal appeal. This is your first line of defense.
What to Include in Your Appeal Letter:
- Your personal information (name, policy number, etc.)
- A copy of the denial letter
- A clear explanation of why you believe the denial is incorrect
- Medical records or doctor’s letters supporting the need for treatment
- Any clinical studies or guidelines showing the treatment is standard care
Address the insurer’s specific reason for denial. For example, if they say it wasn’t “medically necessary,” include a letter from your doctor explaining why it is.
Example Opening:
“I am writing to formally appeal the denial of coverage for [treatment/service] received on [date], which was denied on the grounds of [reason]. As someone with a diagnosed pre-existing condition, I believe this decision is inconsistent with the protections provided under the Affordable Care Act and with the medical necessity of my condition, as documented by my physician.”
Deadline: You typically have 180 days from the date of the denial to file an internal appeal. Check your policy for specific timing.
Step 5: Consider an External Review
If your internal appeal is denied, you may request an external review—a process where a neutral third party evaluates your claim. This is legally binding and can overturn your insurer’s decision.
Under the ACA, you have the right to an external review if:
- Your insurance company denies payment for a treatment it considers not medically necessary
- Your insurer refuses to pay for a service because it’s experimental or investigational
- Your care was ended too early
You usually must request the external review within 4 months of receiving the final denial.
Step 6: Get Help if You Need It
Navigating appeals can be overwhelming. Fortunately, there are resources:
- State insurance departments: Many offer help for consumers with denied claims
- Patient advocacy organizations: Groups like the Patient Advocate Foundation or your condition’s national foundation often provide free help
- Legal aid: If you feel you’re being unfairly denied based on a pre-existing condition, an attorney specializing in health insurance law can help
Bonus Tips for a Successful Appeal
1. Stay Organized
Keep a file with all your paperwork: denial letters, doctor’s notes, medical records, phone call logs, and copies of what you send.
2. Be Clear and Concise
Stick to the facts in your appeal letter. Be polite but firm, and directly address the insurer’s reasoning.
3. Use Evidence
Include test results, prescription records, peer-reviewed articles, or treatment guidelines from trusted medical associations that support your case.
4. Ask Your Doctor for Support
A well-written letter from your physician explaining the medical necessity of treatment can make a huge difference.
5. Follow Up Regularly
Don’t wait passively. Call to confirm your appeal was received, and follow up if you haven’t heard back by the stated deadline.
What If You Still Get Denied?
Even after all appeals, some claims may still be denied. At that point, you can:
- File a complaint with your state’s insurance commissioner
- Seek assistance from your employer’s benefits administrator
- Consider legal action, especially if there’s evidence the denial violates state or federal law
While this step can be more involved, it’s often a last resort when medical treatment is urgent or extremely expensive.
Final Thoughts
Having a pre-existing condition shouldn’t mean you’re left without the coverage you need. While a denied claim can feel like a major setback, you have the right to appeal—and you can win.
Stay proactive, organized, and persistent. Understand your rights, work with your healthcare providers, and don’t hesitate to seek help. With the right approach, you can often reverse a denial and get the care you deserve.