Top 5 Reasons Health Insurance Companies Deny Legitimate Claims—and What You Can Do About It
Legally reviewed By Scott Glovsky in Insurance and Healthcare Denials
When you pay for health insurance, you expect it to be there when you need it most. But too often, patients facing serious illness or injury are met not with support, but with a denial letter. Insurance companies routinely reject valid claims for necessary care, leaving patients confused, angry, and without the necessary treatment.
At The Law Offices of Scott Glovsky, we’ve spent decades helping people challenge unfair health insurance denials. Below are five of the most common excuses insurance companies use—and what you can do if it happens to you.
1. “The Treatment Isn’t Medically Necessary”
Insurers often claim that a recommended treatment or procedure isn’t “medically necessary,” even when your doctor strongly recommends it. This tactic allows them to avoid covering care, regardless of how critical it is to your health.
What You Can Do: Ask your doctor for a detailed letter explaining why the treatment is necessary. If possible, include medical records and clinical studies. If the appeal is denied, legal help may be the next step.
2. “The Treatment Is Experimental or Investigational”
Even FDA-approved treatments can be denied under the label of “experimental.” Insurers use this excuse to avoid paying for cutting-edge therapies, especially for conditions like cancer or rare diseases.
What You Can Do: Gather evidence showing the treatment is widely accepted in the medical community. Appeal the denial and be prepared to fight.
3. “You Didn’t Get Prior Authorization”
Some plans require prior approval for specific treatments. If a doctor didn’t request it or the insurer “didn’t receive it,” they may deny the claim outright.
What You Can Do: Keep records of all communications and ask your provider to confirm whether prior authorization was obtained. You still have a right to appeal.
4. “Out-of-Network Provider”
Even when urgent treatment is unavailable in-network, insurers may deny claims because the provider isn’t in their network.
What You Can Do: If care was unavailable in-network, document your attempts to find it. Some policies include exceptions, and a skilled advocate can help fight for coverage.
5. “Clerical Errors or Missing Information”
Minor technical issues like wrong billing codes or missing documents can trigger a denial—though the underlying care was completely valid.
What You Can Do: Review the denial letter carefully and correct any issues. Resubmit quickly, and keep a copy of everything.
Don’t Fight Alone
If your valid health insurance claim has been denied, you’re not alone, and you don’t have to face it alone. At The Law Offices of Scott Glovsky, we’re committed to fighting insurance companies that put profits over people. Contact us today to discuss your case and learn how we can help you get the care you deserve.