Insurance Claim Denied

For ACA-compliant individual/group health plans: federal internal appeal / external review rules; for employer self-funded plans: ERISA claims procedure; for other insurance (auto, home, life): state insurance department complaint route.

Internal appeal

You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied. The insurer must notify you of a denial within 15 days for prior authorization, 30 days for services already received, or 72 hours for urgent care. The internal appeal itself must be completed within 30 days (service not yet received) or 60 days (service already received); for urgent situations, a decision must come within at least 4 business days, with written notice following within 48 hours.

External review

If the internal appeal is denied, you can request an independent external review; the insurer's final determination must explain how to request one.

Source →

FCA Handbook ICOBS 8 (Insurers: general) claims-handling rules, plus the Financial Ombudsman Service complaint route

ICOBS claims handling

ICOBS 8.1.1R: an insurer must (1) handle claims promptly and fairly; (2) provide reasonable guidance to help a policyholder make a claim and appropriate information on its progress; (3) not unreasonably reject a claim (including by terminating or avoiding a policy); and (4) settle claims promptly once settlement terms are agreed.

Unreasonable rejection

ICOBS 8.1.2A guidance: rejection is considered unreasonable (among other cases) for a misrepresentation that isn't a 'qualifying misrepresentation', or for breach of warranty/term/fraud where the insurer can't rely on the relevant Insurance Act 2015 provisions.

Complaint route

A business has 8 weeks to consider most complaints (15 days specifically for fraud/scams, payment services, or e-money complaints) before the consumer can refer it to the Financial Ombudsman Service; the consumer then has 6 months from the date of the firm's final response to bring the complaint to the Ombudsman.

Source 1 → · Source 2 →