When a valid claim gets denied, delayed, or low-balled, it’s not the end. It’s a contract dispute—and you have rights. On federal marketplace plans, nearly 1 in 6 in-network claims were denied in 2021, with some plans far higher. Yet most people never appeal. Our job is to turn a bad answer into a paid claim
<https://www.kff.org/private-insurance/claims-denials-and-appeals-in-aca-marketplace-plans/>
Why insurers deny claims (and what it really means)
Common reasons include “not medically necessary,” “not covered,” out-of-network, coding errors, missing records, late filing, or alleged policy lapse. Many of these are fixable with the right evidence and timeline control.
What to do right now
- Get the denial letter and your policy/plan booklet. The reason and deadlines are key.
- Organize proof: doctor notes, test results, bills/EOBs, photos, police reports, or receipts—whatever fits the claim.
- File the internal appeal on time (often 30–180 days). Add a doctor support letter for medical denials.
- Ask for an external/independent review if the internal appeal fails; also consider a complaint to your state insurance department.
- Call a lawyer early—we protect deadlines, fix the record, and deal with the carrier.
How we build your appeal (and lawsuit if needed)
- Policy analysis: we map benefits, exclusions, riders, and notice limits.
- Record building: we cure “missing info,” get expert letters, and correct coding.
- Deadline control: we file clean, on-time appeals and demand letters.
- Litigation: if the carrier breaches the contract or acts in bad faith (unreasonable denial, delay, or failure to investigate), we sue for the benefits due and other remedies allowed by law.
Types of denials we handle
Health insurance Claims and Personal Injury (treatment, meds, prior auth), disability (STD/LTD), life insurance, long-term care, property (home/auto), and business claims.
Why acting fast matters
Insurers count on low appeal rates. One PBS analysis found more than 49 million claims denied in 2021 and <0.2% appealed—timing and persistence change results. We take over the process so you can focus on recovery or getting back to work.
<https://www.pbs.org/newshour/show/how-algorithms-are-being-used-to-deny-health-insurance-claims-in-bulk?utm_source=chatgpt.com>
What you may recover
Plan or policy benefits owed, interest, penalties where allowed, and in some cases fees or extra damages for bad-faith conduct (depends on the policy and law; we’ll explain your options after review).
Free case review. Bring us your denial letter and policy; we’ll tell you your best next step. Call (210) 996-2237.
