Insurance Claim Denied? How to Appeal It — and Who to Complain To

The letter is one page and mostly boilerplate. Somewhere in the middle sits a code and a sentence that means we're not paying this. You called. The person on the phone was sympathetic and completely powerless, and read the same code back to you.

Here's the reframe, and it matters more than anything else below: you are probably not appealing a medical judgment. In KFF's analysis of in-network claims in 2024 ACA marketplace plans, only 5% of denials were for lack of medical necessity. 25% were administrative. A quarter of denials are, at bottom, paperwork — and paperwork is the kind of denial an appeal fixes fastest.

Meanwhile a clock the letter probably buried is already running.

Here's the ladder, in order.

Who Regulates Your Insurance Plan? That Decides Where You Appeal

Almost every guide on this topic ends with "contact your state insurance department." For a lot of readers that is the wrong door, and finding out costs weeks you may not have.

• Marketplace, individual, or fully-insured employer health plan → your state Department of Insurance, plus the ACA external review process.
• Self-funded employer health plan (ERISA) → the plan's internal appeal, then the Labor Department's Employee Benefits Security Administration; external review runs through the plan's independent review organization. A state DOI has no jurisdiction here.
• Medicare Advantage or Part D → CMS's five-level appeal ladder: plan reconsideration, then an Independent Review Entity, then an Administrative Law Judge, then the Medicare Appeals Council, then federal court. The detail worth knowing sits in the regulation rather than that overview page: under 42 CFR § 422.590, if the plan affirms its own denial at Level 1, it must send your case file to the CMS-contracted independent entity. You don't re-file.
• Auto, home, or property → state DOI, plus the appraisal clause in your own policy.
• Life or individual disability → state DOI. Group coverage through an employer is ERISA.
• The unpaid bill now in collections → that's a CFPB matter, but the denial itself isn't. More on that below.

How to find out which you have: ask HR whether your plan is self-funded or fully insured. ProPublica's Claim File tool walks the same fork — DOL for private employer plans, CMS for state and local government plans, OPM for federal employees, state agencies for individual and marketplace coverage.

How Long Do You Have to Appeal an Insurance Denial?

HealthCare.gov gives you 180 days from the denial notice to file an internal appeal, and 4 months from the notice or final determination to request an external review. Write both dates down before you do anything else.

The insurer is on clocks too. Per HealthCare.gov, it must notify you in writing and explain why within 15 days for a prior authorization, 30 days for services you've already received, and 72 hours for urgent care. Once you appeal, it must complete the internal appeal within 30 days for a service you haven't had yet, or 60 days for one you have. And its final decision "must tell you how to ask for an external review."

If your coverage comes through an employer, the governing regulation is 29 CFR § 2560.503-1: plans must give you at least 180 days to appeal, and must decide within 72 hours (urgent), 30 days (pre-service), 60 days (post-service), or 45 days (disability). And the part worth quoting back at them is in the regulation itself — your appeal must be reviewed by a named fiduciary who is neither the individual who made the original determination nor that person's subordinate.

Step 1: Request Your Claim File Before You Write the Appeal

This is the step almost nobody takes, and it's the difference between arguing and rebutting.

Your claim file is, in ProPublica's words, "a collection of the information your insurer used to decide whether it would pay for your medical treatment or services… internal correspondence, recordings of phone calls, case notes, medical records and other relevant information." Under § 2560.503-1 you're entitled, "upon request and free of charge," to "reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits."

Free. On request. Ask in writing:

Under 29 CFR § 2560.503-1, I request, free of charge, reasonable access to and copies of all documents, records and other information relevant to claim #12345 — including internal correspondence, case notes, call recordings, the specific plan provisions relied on, and any internal rule, guideline or protocol applied in denying it.

ProPublica's tool will generate that letter for you. Set expectations honestly: they say you should get a response within 30 days, while also reporting that "some insurers can be unresponsive," with people receiving files anywhere from one to three months later, or never. Send it anyway, on day one, and start the appeal in parallel. What comes back is often the appeal.

Step 2: How to Request an External Review — Almost Nobody Does

Here is the most surprising sentence available on this subject, and it's HealthCare.gov's, not ours: "Your insurer is required by law to accept the external reviewer's decision."

An independent reviewer, a binding outcome, and almost no price. Under the HHS-administered federal process there's no charge; where a state process or a contracted review organization applies, the fee "can't be more than $25." Standard reviews are decided "no later than 45 days"; expedited ones "no later than 72 hours." Any denial involving medical judgment qualifies, as does one calling a treatment experimental or investigational. If your case is urgent, you can file the internal appeal and the external review request at the same time — and you can appoint your doctor to file for you.

If your plan uses the federal process — per CMS, that's Alabama, Florida, Georgia, Texas, Wisconsin, territories other than Puerto Rico, and state or local government plans anywhere — file through the HHS federal external review portal that HealthCare.gov links to, or call 1-888-866-6205 to request a paper form.

Now the scale. KFF counted at least 5,881 external appeals against roughly 85 million denied in-network claims in 2024. Fewer than 1% of denied in-network claims were appealed at all. ProPublica's reporting explains part of why: external reviews are "one of the industry's best-kept secrets, and only a tiny fraction of those eligible actually use them." In one case it documented, the instructions were "buried on page seven of one of the denial letters."

You don't have to do it alone, either. ProPublica reports that roughly 30 states fund consumer assistance programs, and HealthCare.gov notes that your state program can file the appeal for you. In Connecticut, ProPublica reported in October 2025, the state's Office of the Healthcare Advocate resolves or overturns denials in the patient's favor about 80% of the time — that's Connecticut's number, quoted to that office's Kathleen Holt, not a national one.

Step 3: How to Escalate Above the Claims Department

Internal appeal and external review are processes. They grind forward whether or not anyone at the insurer cares. The executive escalation is the separate move that gets a human with authority to own your file while those clocks run. Do both, not either — escalating to the C-suite works precisely because it changes who is accountable for the outcome.

The refinement most people miss: write the claims executive, not just the CEO. A claims chief owns the decision a CEO's office would only forward. As publicly listed on their employers' own leadership pages as of August 2026, State Farm has Jon Farney as president and CEO and Wensley J. Herbert as Senior Vice President, P&C Claims; Progressive has Tricia Griffith as CEO and president and John Murphy as Claims President; Allstate has Tom Wilson as chair, president and CEO. On the health side, Stephen J. Hemsley is CEO of UnitedHealth Group and Tim Noel is CEO of UnitedHealthcare; Brian Evanko became CEO of The Cigna Group on July 1, 2026.

Two rules before you send. Verify the name this week, on the company's own leadership page or newsroom — third-party contact directories and search results rot badly. Cigna's chief executive changed on July 1, 2026, and directories and search summaries were still returning David M. Cordani well afterward; the same staleness shows up for State Farm and UnitedHealth Group, both of which changed CEOs recently. And ladder up rather than opening at the CEO: start with the front-line contact, then the named business-unit executive, then the chief executive, so you leave a documented trail. Any email address floating around a public directory is crowd-sourced and unconfirmed by the company — treat it as a lead to check, never as a fact.

Step 4: How to File a Complaint Against Your Insurance Company

"File a complaint with your state insurance department" is inert advice until you know why it works. It works because it puts the insurer on a regulator's clock. In Washington, the OIC says the company's response is due in 15 business days. In Indiana, state law gives it 20 business days to respond in writing to the department. Someone senior now has a deadline attached to your name.

Find your state's department through the NAIC's consumer directory. Per NAIC, your state DOI can investigate complaints for free involving "unfair claim delays or denials, failure to honor your policy, violations of state insurance laws, lack of timely communication." The volume is real: California's Department of Insurance says it investigates more than 56,000 consumer complaints a year and recovers more than $130 million for consumers (hotline 1-800-927-HELP). NAIC's Consumer Information Source also lets you pull a company's closed-complaint history before you write.

Then the honest part, which no competitor prints. Washington's OIC states plainly what it cannot do: act as your lawyer, give legal advice, interpret your policy language, provide medical opinions, decide who's at fault, or determine what a repair should cost. A complaint forces a documented response. It is not a verdict.

Two corrections while you're here:

• The CFPB is the wrong door for the denial. Dodd-Frank Title X excludes the business of insurance from CFPB oversight, consistent with McCarran-Ferguson. It becomes the right door the moment the unpaid bill hits collections or your credit report, where the FDCPA and FCRA apply — the same mechanics as when a bank denies your dispute.
• No Surprises Act dispute resolution isn't yours to file. CMS describes IDR as a process providers, facilities and health plans use with each other. Your resource is the No Surprises Help Desk, 1-800-985-3059.

How to Dispute a Denied Car or Home Insurance Claim

Different ladder, and one distinction decides which rung you're on.

If it's a coverage dispute — they say the loss isn't covered at all — you're on internal appeal, DOI complaint, and possibly a lawyer. If it's a valuation dispute — they agree it's covered and the number is insulting — the remedy is the appraisal clause in your own policy. Each side names an appraiser, the two select a neutral umpire, and you split the umpire's cost. It's contractual, comparatively cheap, and it generally can't resolve a pure coverage denial. Check your own policy for the exact terms, since they vary.

One warning: the 180-day federal window is a health-plan rule. Auto and home appeal deadlines are set by your contract and your state. Read the policy for yours.

The Denied-Claim Checklist: What to Do, in Order

1. Identify who regulates the plan that denied you — DOI, DOL, or CMS.
2. Write down your 180-day appeal date and your 4-month external review date (health plans; auto and home run on your contract).
3. Request your claim file in writing, today, free of charge.
4. File the internal appeal — simultaneously with external review if it's urgent.
5. Escalate to the named claims executive, with a title you verified this week.
6. File the external review. It's binding, and it's $25 at most.
7. File with the DOI, DOL or CMS — and CFPB only once the bill is in collections.

All of that is free, and you should do every step of it. What it costs is attention — and the piece that rots fastest, and takes the most work to get right, is identifying who actually owns the decision and writing something that lands on their desk instead of in a queue.

That's what DearCEO.wtf is for: AI-researched executive contacts rated high, medium or low confidence, and a professional escalation email built from your own facts — usually generated in under five minutes, with two free revisions. You review and send it yourself, from your own account. One flat price per email, no subscription (pricing); or work through the free DIY guide instead (free account required).

No promises about your claim — a regulated insurance denial is a process with its own rules, and nobody can guarantee where it lands. But the KFF numbers are the whole argument for trying: fewer than 1% of denied in-network claims are ever appealed, and insurers upheld 66% of the appeals that were filed — which leaves roughly a third they did not uphold.

Almost nobody bothers.