Which rules govern your plan
The first question in a health insurance claim dispute is what kind of coverage you have. Most plans offered through private employers are governed by a federal law called ERISA, which sets claim and appeal procedures and can limit what a court later reviews. Self-funded employer plans, where the employer bears the cost of claims, are generally not regulated by state insurance law. Individual plans and insured group plans are subject to state insurance regulation as well, which in New York runs through the Department of Financial Services. Medicare and Medicaid have separate appeal systems of their own. Your explanation of benefits, plan documents, and insurance card can usually tell you which category applies.
Appeals have their own clock
Most denials must first be appealed within the plan, and the deadline to file that appeal can pass while you are still waiting on calls to customer service. Request the denial in writing, the specific plan provision relied on, and the clinical criteria used, which plans are generally required to provide. A letter from your treating physician explaining why the treatment is necessary for you, with supporting records and published research, is often the most important part of an appeal. If the internal appeal fails, many plans allow an external review by an independent reviewer, and in New York a state-regulated plan's external appeal runs through the state. Urgent situations can qualify for expedited review.
When the bill itself is the problem
Some disputes are about billing rather than coverage, such as unexpected out-of-network charges for emergency care or from providers you did not choose. Federal law and New York law both provide protections against many surprise bills, with dispute processes for qualifying situations. If an ERISA plan denies a claim after appeal, a lawsuit in federal court is possible, but the court often reviews only the record created during the appeal, which is why the appeal should be thorough. Your plan type, the denial reason, and the deadline that is running are what we pin down first. From there we decide with you whether the next step is a stronger appeal, an external review, or litigation.
