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What to do If Your Pennsylvania Health Insurance Claim is Denied

If Your Health Insurance Claim is Denied

If your health insurance claim is denied, you first should review your health insurance policy or employee benefits booklet to determine the appeal rights provided to you under the policy. If you do not have a copy of your health insurance policy or employee benefits booklet, contact the health insurance company's customer service unit to inquire about the appeal procedures.

You may be required to file a written appeal and to provide information from your doctor supporting your dispute. If you remain dissatisfied after exhausting the appeal mechanism provided by your policy, contact the Pennsylvania Insurance Department to request assistance in determining other remedies or rights you may have.

In order for the Pennsylvania Insurance Department to assist you in an efficient and effective manner, the following information is needed to address your complaint:

• Name of the health insurance company and/or plan;
• Identity of the health insurance sponsor (i've employer, government or individual);
• Identification of the specific type of coverage: (i've Fee-for-Service, HMO, PPO);
• Type of Policy: (i.e. Major Medical, Hospital Indemnity, Disability, Long- Term Care) including policy number or certificate number;
• Nature of the dispute; and
• Actions you have taken to resolve the problem.