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The Voice of People With Breast Cancer


Our Voices Blog

What Happens if a Life or Health Insurance Company Denies Your Claim?

By OmbudService for Life and Health Insurance (OLHI)

This blog has been adapted from the OLHI’s website, originally posted here.

To learn more about the OLHI read our Q & A here.

A breast cancer diagnosis comes with so many fears and challenges. The last thing you need on your mind is the worry about whether your insurance claim will be approved or denied. Appealing a denied claim can add an additional burden to an already difficult time. Some people don’t even realize that are able to appeal their denied insurance claims. But how do you do it?

Step 1: Appeal your denied claim
If your life or health insurance claim gets denied, a Case Manager will send you a claim denial letter. Each submitted claim gets assigned to a Case Manager, whose job is to review these claims to see if they are payable—or not.

A claim denial letter will provide step-by-step instructions on how to appeal your denied claim. You’ll likely need to provide additional details (in writing) to your insurer to clarify the context of your claim.

If you receive a second claim denial letter, now you have the grounds to file a complaint.

  • Tip: Be calm and polite. Trying to resolve a complaint can be frustrating and stressful. Our experience is that a courteous manner leads to an easier and faster resolution.

Step 2: Submit your life or health insurance complaint to a Complaint Officer
Once you’ve unsuccessfully appealed your denied claim, you can escalate your situation to a Complaint Officer at your insurance company.

A Complaint Officer has the authority to make a final decision about your complaint.

  • Tip: Submit your complaint in writing. It’s usually best to send your complaint in writing. Many insurance companies will have an email address or online form you can use to make your complaint. You may also be able to send it by mail.

Before sending your complaint, contact your insurance company to determine to whom you should address your complaint and what documentation you need to attach.

OLHI has a Consumer Complaint Officer Listing tool that allows you to quickly find the contact information for your insurance company’s Complaints Officer. (If you don’t see your insurance company on this list, it means they aren’t a member company of OLHI.)

  • Tip: How to format your written insurance complaint
    • Put “Complaint” at the top of your letter or in the subject of your email.
    • Be clear about what went wrong and when. 
    • Tell your insurance company what you expect as a solution.

Step 3: Submit your life or health insurance complaint to a Complaint Officer.
Once you complete your insurance company’s complaint process, you will receive a “final position letter.” If you don’t receive a final position letter, ask for one from the Complaint Officer.

Here’s what you can expect to see in a final position letter.

All insurance companies have an internal complaints process, which you must follow to obtain a Final Position Letter from your insurer before you bring your complaint to us at the OmbudService for Life and Health Insurance (OLHI).

Once you have received a Final Position Letter, you can submit your complaint to us.

Got your Final Position Letter? Here’s the next step:
Once you have received a Final Position Letter from your life or health insurance provider, you can submit a complaint to our ombudservice.

If your complaint is reviewable and has merit, we can provide another impartial review of your insurer’s final position on a health or life insurance claim.

Take a few minutes to learn more about our complaints process so you know what to expect: see the full complaints process.

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