Why Few End Up Appealing Denied Health Claims — And How You Can Be the Exception
Every year, millions of Americans receive a health insurance denial. A test, treatment, surgery, hospital bill, or specialist visit is rejected—often without valid justification. But what most people don’t realize is this:
Less than 1% of denied claims are ever appealed, according to the Kaiser Family Foundation (KFF).
That’s not a typo.
Not 20%.
Not 10%.
Less than one percent.
Which means something else:
Insurers count on you NOT appealing.
But here’s the part patients never hear:
When you do appeal, your chances of getting the denial reversed are surprisingly high.
This blog explains why most people don’t appeal, why insurers expect you to give up, and how YOU can be the exception by learning how to appeal a denied claim effectively.
You’ll also learn how to use my FREE Appeal Guide and attorney-drafted DIY appeal letter templates to send a strong, structured appeal letter that gives you a real chance at approval.
The Shocking Truth: Less Than 1% Appeal Their Denied Claims
According to the latest KFF analysis, less than 1% of denied claims under ACA marketplace plans are appealed—even though denial rates can be as high as:
11%
18%
20%
Even 30%+ depending on the insurer
This means millions of valid claims go unpaid simply because patients don’t know their rights.
So why do so few people appeal? Below are the real reasons.
❌ Reason #1: People Assume the Insurance Company Must Be Right
Most people trust the insurer’s initial decision. They believe:
“If they denied it, I must not be covered.”
“Maybe I made a mistake.”
“The doctor probably didn’t follow the rules.”
But the truth?
Most initial denials are automatic and lack real medical review.
Many are based on:
Missing paperwork
Incorrect billing codes
Lack of prior authorization (even when requested)
Automated system triggers
Misinterpretation of guidelines
Your denial DOES NOT mean the care wasn’t medically necessary or covered. It often just means you need to explain it more clearly—and that’s exactly what an appeal is for.
❌ Reason #2: Denial Letters Are Intentionally Confusing
Insurance companies know that if they keep explanations vague, most people will give up.
Common phrases include:
“Not medically necessary”
“Not covered under your plan”
“Insufficient information provided”
“Experimental or investigational”
“Out-of-network provider not authorized”
None of these mean you’re out of options. They simply describe the insurer’s current opinion—not the final decision.
A denial is NOT final unless you stop fighting.
❌ Reason #3: People Feel Intimidated by the Appeal Process
Many assume appealing is too complex or requires a lawyer. But a health insurance appeal is simply:
A letter
A few supporting documents
Sent to the insurer within their stated deadline
You don’t need legal training.
You don’t need insurance expertise.
You only need a structured approach—which is why templates help so much.
❌ Reason #4: People Don’t Know Their Legal Rights
Under federal law (ACA & ERISA), you have the right to:
✔️ A full and fair internal appeal
✔️ A second, independent external review
✔️ A review by a medical specialist
✔️ The insurer’s internal guidelines
✔️ A written explanation for denial
Insurers very rarely explain these rights in plain language—which is why people don’t use them.
❌ Reason #5: People Think the Appeal Won’t Work
This is the biggest misconception.
Research shows that when people do appeal, many denials get overturned—because the original denial was flawed, incomplete, or automated.
In fact:
A strong appeal letter that includes medical records, doctor statements, and evidence has a high chance of success.
Especially for:
Prior authorization denials
Medical necessity denials
Out-of-network emergency care
Preventive care misclassified as diagnostic
Billing and coding errors
No in-network provider available
Appealing works—if you do it properly. To learn more about how to appeal, get my FREE APPEAL GUIDE HERE.
💡 Why YOU Should Be the Exception
When you appeal:
You force the insurer to do real review
You gain access to the insurer’s internal guidelines
The denial is reviewed by a new medical professional
You activate legal protections
You dramatically increase your chance of approval
Insurance companies count on silence. Your appeal letter disrupts the denial process and requires them to justify their decision. That’s why appealing is powerful. In my FREE Appeal Guide, I give legal tips on submitting a winning appeal.
Appeal Success Stories
⭐ Example #1: Preventive Labs Denied, Reversed After Appeal
A woman received a $500 bill for routine lab work during her annual exam. The insurer denied the claim because the labs were miscoded as “diagnostic.”
She appealed, explaining:
The labs were preventive
The visit was an annual exam
The coding was incorrect
ACA requires preventive care coverage
The insurer reversed the denial within 30 days.
⭐ Example #2: MRI Denied as “Not Medically Necessary”
A man with chronic back pain had an MRI rejected.
The denial letter was two sentences long.
He appealed using:
Orthopedist notes
X-ray results
Physical therapy failure records
Appeal template language requesting “specialist review”
The MRI was approved on appeal.
⭐ Example #3: Out-of-Network ER Visit Denied
A teenager fainted while traveling.
The nearest hospital was out-of-network.
The insurer denied the claim.
Her parent appealed using emergency care federal protections that require in-network rates for emergencies.
The insurer reprocessed and paid 90% of the bill.
📝 How to Appeal a Denied Health Insurance Claim (Step-by-Step)
Here are the key denied health insurance claim steps you should follow:
1. Request Your EOB + Denial Letter
This tells you:
The denial code
The reason for denial
Missing documentation
Appeal deadline
2. Gather Supporting Evidence
This may include:
Doctor’s notes
Medical records
Lab results
Imaging reports
Referral notes
Billing corrections
Prior authorization confirmations
3. Write a Strong Appeal Letter
Your letter must include:
Your demographic information
Denial details
Why the denial is wrong
Supporting medical evidence
Federal protections (ACA or ERISA)
A request for reprocessing
A demand for specialist review
This is why templates are so useful.
4. Submit the Appeal on Time
Deadlines are strict.
Missing a deadline kills your appeal.
5. Request an External Review
If the insurer still denies your appeal, you have the right to a third-party, independent review.
External reviewers overturn many denials.
Step 1: Download Your FREE Appeal Guide
If you feel overwhelmed by the insurance denial process, my FREE Appeal Guide gives you:
Appeal checklists
Step-by-step instructions
Sample arguments
Questions to ask your doctor
Documentation tips
Internal vs. external review guidance
👉 Download Your FREE Appeal Guide Here
📝 Step 2: Use a $29 Appeal Template (Most Effective Method)
If you need a customizable ready-to-send appeal letter, my $29 templates give you:
Professionally structured legal language
Arguments for medical necessity, prior authorization, preventive care, out-of-network denials, and more
Fill-in-the-blank sections
ERISA and ACA citations
Space for medical evidence
Simple instructions
👉 Get the $29 Appeal Template Here
This is the fastest, most effective way to become the 1% who appeals—and wins.
Be the Exception
Insurance companies rely on patients giving up. When only 1% appeal, insurers profit from the silence.
But YOU can be the exception.
Appealing a denial increases your chances dramatically—especially when you use:
A structured template
Medical evidence
Your legal rights
A clear, powerful letter
Your health is worth fighting for. Your coverage is worth fighting for. And you have the tools to win.
