What Can I Do If My Health Insurance Company Won’t Give Me a Written Denial?

If you are currently dealing with an insurer who is denying medically necessary treatment, you know that few things in life are as frustrating. If your insurer is also refusing to explain the claim denial decision in writing, that frustration can multiply exponentially. Every single day you spend trying to get your denial in writing is one more day you are not receiving the treatment your doctor believes you need. This means another day without the medication you need, a necessary surgical procedure, tests to help your doctor make a diagnosis, therapy, or other necessary care. A written denial from your insurer matters more than you may realize.

When you receive a written claim denial, it must provide the insurer’s reason for the denial. The specific denial reason gives you and your medical provider the information you need to challenge the decision. California law requires written notice for most health insurance denials, delays, or modifications, yet some insurers deliberately make denials harder to contest by withholding the paperwork. While this can seem like a hopeless situation, there are specific steps you can take that both protect your health and your right to challenge the decision. 

If your doctor’s office has told you that a procedure, treatment, or medication has been denied, yet when you ask your insurer for a denial letter, nothing arrives, you could potentially benefit from speaking to an experienced medical claim denial attorney from the Law Offices of Scott Glovsky. Scott has been helping people just like you for decades. He and his team fight for justice every single day, using every legal tool available. Do not simply accept a claim denial, particularly one that has no denial letter to back it up. A health insurance denial should never be a mystery, and you do have legal protections under California law.  

Learning Your Medical Procedure, Treatment, or Medication Has Been Denied

Perhaps you were notified by phone or in person by your doctor, pharmacist, medical portal, or provider that treatment has been denied. This is different than receiving a letter in the mail from your insurer denying treatment. When you receive a letter in the mail from your insurer, it will include the reason for the denial. Without that letter, you may not know the reason, and without that information, you cannot fight back. 

You may have repeatedly requested the actual denial letter from your insurer only to have those requests go unanswered. A verbal denial creates a serious problem for you, as you are unable to determine which policy provision or medical necessity criterion was applied. This leaves you in the dark as to what evidence you need to have the denial overturned, making the appeal process much more difficult.  

Is My California Health Insurance Company Required to Provide a Written Denial?

In almost every situation, your California health plan or health insurer must clearly communicate its decision to deny, delay, or modify a requested health care service to you in writing. This written notification tells you why the service was denied and what you can do to challenge the decision. California Health and Safety Code Section 1367.01 requires health care plans that are regulated by the California Department of Managed Care (DMHC) to communicate these decisions to the insured in writing. 

This means that a clear explanation of the insurer’s decision, the guidelines used to make that decision, and, if lack of medical necessity is the reason, the clinical reasons for that decision must be revealed. There are similar requirements regarding health insurance policies regulated by the California Department of Insurance under Code Section 10123.13. Under this requirement, the insured must be notified in writing within 30 days from the date the claim is received. This notification must identify what specifically has been denied and provide specific reasons for the denial. 

The written denial cannot include vague language or claim the treatment is not medically necessary without a full explanation of the reasons for the decision and a description of the criteria or guidelines used to deny the claim. Under DMHC-regulated plans, the response must explain the clinical guidelines or medical policies relied on to make the denial determination and must explain the California Independent Medical Review process, also known as the external review process. 

In other words, your denial letter cannot simply say a service is not a covered benefit. The relevant exclusions or limitations in your plan documents must be clearly identified, along with an explanation of how they apply in this situation. In short, a telephone call from your medical provider or an insurance representative is not a substitute for a written denial letter required under California law. Further, your denial letter must distinguish:

• A denial of authorization for your future treatment
• A delay or modification of your requested treatment
• A denial of a claim for treatment you have already received
• A denial that is based on the lack of medical necessity
• A denial that is based on your specific policy coverage or exclusion

How Quickly Must Your California Insurer Provide a Written Denial Letter?

If your insurance plan is regulated under the DMHC, then most denials, delays, or modifications that involve prospective or concurrent authorization must be communicated to you in writing within two business days from the date of your insurer’s denial decision. Insurers regulated by the California Department of Insurance (CDI) also have a two-business-day requirement for most medical-necessity authorization decisions.  California Insurance Code Section 10123.13 establishes separate claim processing requirements for urgent requests, and, in general, the deadline for a written denial letter depends at least somewhat on the type of request and on your specific plan.  

Why Does Getting Your Claim Denial in Writing Matter So Much?

Getting your claim denial in writing does the following:

• Your insurer’s decision for the denial is clearly established.
• Having the denial reason established prevents that denial from later shifting. 
• Getting your denial in writing sets forth the evidence required for an appeal. 
• Your physician is able to prepare a medical-necessity response once the denial is in writing. 
• A written denial creates documentation for grievances, appeals, regulator complaints, and even a potential insurance bad-faith claim. 
• A written denial establishes important dates. 

If your claim denial is not in writing, you are unable to challenge the denial because you do not know what the decision was or why it was made. Receiving a vague verbal explanation from your insurer’s customer representative can involve incomplete information or may even be inconsistent with the actual claim denial reason. A written denial creates a clear record of your insurer’s position. Depending on your plan, the denial should identify the service or treatment being denied, the reasoning behind that decision, any medical criteria or plan provisions involved, and your rights to challenge the decision. 

A written decision tells you what you are fighting and can help your doctor respond with your medical records and other evidence supporting the requested treatment. Having the insurer’s decision in writing helps preserve your right to appeal and, for certain California plans, can also provide information about the right to seek an Independent Medical Review (IMR). Finally, once a claim denial is in writing, your insurer cannot later change its reasoning for the denial; a written denial establishes a clear paper trail.  

What Can I Do If My California Insurer Denies My Treatment Only Over the Phone?

While it can take you by surprise to receive a phone call from your California health insurer, it is important that you fully document the phone call. Write down the time of the call, and immediately ask the representative for his or her name and the reason for the denial, along with a denial/reference number. Ask when the decision was made and who made the decision, then request a written notification letter of the denial. Document all the information you were given, along with the fact that you requested written notification. 

Above all else, never assume the telephone call is the end of the matter. Follow up the phone conversation with written communication detailing the call you received and, once again, requesting a written denial letter. Make sure to ask your medical provider whether they received a denial letter on your behalf, and keep all screenshots from portals, along with copies of any of your messages you sent or received. 

If you are told your insurer does not provide written denials, document that response, writing down the date and time of the call, the representative’s name or identification number, the telephone number you called, and exactly what you were told. Follow up through your insurer’s secure online portal, email, or any other method that involves a written record. Keep in mind that your doctor’s office may have received information that you did not, since providers are allowed to initially receive certain utilization-review decisions by telephone or fax, followed by written communication. If your medical provider has received written communication regarding your denial, request a copy for your records.

Generally speaking, you do not have to simply sit around and wait for paperwork before you file a grievance regarding the lack of written documentation. For DMHC-regulated plans, you can file a grievance with your insurer by telephone or in writing, and certain plans permit grievances through their website. Health insurers generally have 30 days to resolve a grievance. In your grievance, explain that the treatment was verbally denied, identifying the date you learned of the denial via phone call and that you have requested a written denial. Ask your insurer to reconsider the treatment decision and provide the required written denial letter.  

You could also file a complaint with the DMHC Help Center if your plan is regulated by the DMHC, but you must usually file a grievance with your health plan first. If you are dissatisfied with your insurer’s decision or you have not received a decision within 30 days, you can then seek DMHC assistance. If your situation is urgent, meaning there is an immediate threat to your health, then different timing rules may apply. 

If your healthcare plan is regulated by the California Department of Insurance, you can file a complaint with the CDI. If the dispute involves medical necessity, an experimental or investigational treatment for a serious medical condition, or emergency care disputes, you may qualify for an Independent Medical Review. This review allows independent medical professionals rather than your insurer to review qualifying medical coverage decisions. 

The most important takeaway is that you should never allow your insurer’s failure to send a denial letter to prevent you from challenging the denial. Request the decision in writing, document your communications, involve your physician, and use the appropriate grievance, regulatory complaint, or IMR process. If the process seems overwhelming, discuss the issue with an experienced claim denial attorney like Scott Glovsky.  

What If Your Claim Wasn’t Actually Verbally Denied?

In some cases, the insurance representative on the other end of the phone may say something like:

• “Your claim is still under review.” 
• “We need more information from you.” 
• “Your healthcare provider needs to submit the claim differently.” 
• “The request has been closed.” 
• “A new authorization is required from your healthcare provider.” 
• “This is being handled by the medical group.” 
• “We are redirecting you to another provider.” 

The word “denied” does not necessarily have to be used for there to be a problem. While any of the above statements can describe a legitimate pending or contested claim, they are just as often a way for your insurer to avoid the written notice requirement. For example, “under review” can mean your insurer needs additional medical records, billing information, coding information, or other documentation before it can determine whether your claim is payable. However, under the California Insurance Code, your insurer must generally reimburse a complete claim within 30 calendar days after receiving it unless it is contesting or denying the claim. If the insurer is contesting or denying the claim, you must be notified in writing within that 30-day period.

If you are told your claim needs to be “submitted differently,” there may be a legitimate administrative problem. Perhaps your provider used the wrong billing code, submitted the claim to the wrong entity, omitted required information, or another deficiency needs correction. This does not necessarily mean the insurer has denied coverage. California law recognizes the distinction between paying a claim, contesting it, and denying it. A claim can be contested because it lacks information reasonably necessary to determine its liability. Keep in mind that California law not only addresses outright denials – it also repeatedly uses the words “deny, delay, or modify.” 

When there is no clear denial, it becomes even more important to document every interaction. A secure portal message to your insurer could say something like: “I was advised via telephone on (date) that my claim remains under review. Please confirm in writing the current status of my claim; whether it is complete, is being contested or delayed, and any additional information. Please also let me know when I can expect a determination on this claim.”  

How the Law Offices of Scott Glovsky Can Help with Your Verbal Claim Denial

If you have received a verbal claim denial, Attorney Scott Glovsky can help. Scott has extensive experience representing California policyholders in health insurance disputes. He began representing policyholders in our firm in 1999 and has been fighting for justice ever since. If your insurer has not provided a straightforward written decision, Scott and his legal team can review your policy, claim history, correspondence, medical records, and communications with your insurer to determine whether the company is legitimately processing the claim or improperly delaying a decision. 

The Law Offices of Scott Glovsky can help identify your insurer’s actual reason for refusing payment or treatment and determine which appeal or other remedies may be available. We will ensure you do not have to spend weeks making telephone calls without knowing whether your claim has been denied, delayed, contested, or lost in the administrative process. If you are unable to get a clear written answer about your claim, contact the Law Offices of Scott Glovsky online or call 626-243-5598.