Health Insurance

Health insurance is supposed to give you reliable access to care, treatment when you need it, and financial protection when life takes an unexpected turn. But when your insurer denies a claim or questions your coverage, that security can disappear overnight.

Thankfully, denied claims aren’t the end of the road. You can fight back against their decision, file an appeal, and make them answer for delaying the restitution you need to get back on your feet. This process isn’t always easy, but you don’t have to do it alone – The Nation Law Firm is right around the corner, ready to support you every step of the way.

Since 1997, The Nation Law Firm has helped Florida policyholders stand up to health insurers that delay, deny, or wrongfully limit coverage – and recovered the fullest extent of what they were entitled to. If you’re struggling to get the care you need or the benefits you’ve paid for, we’re here to help you understand your rights and take action.

Complete a free case evaluation to get started with our team.

8 Common Reasons Health Insurance Claims Are Denied

Health insurance claim denials are more common than they should be. Insurance companies treat claims like paperwork instead of treating each claim with respect, often resulting in unfair delays and denials.

Here are the most common reasons health insurance claims are denied in Florida:

1. Lack of Prior Authorization or Referral: Many insurance plans require prior authorization for specific services or treatments before approving a claim. Failing to obtain this approval can lead to claim denials, even if the service is medically necessary.
2. Out-of-Network Provider Usage: Receiving care from providers outside your insurance network can result in denied claims or higher out-of-pocket costs.
3. Administrative Errors: Simple mistakes, such as incorrect billing codes, misspelled names, or incomplete information, can cause claim denials. 
4. Services Deemed Not Medically Necessary: Insurers may deny claims if they determine that the treatment isn’t medically necessary based on their guidelines, even if your doctor recommends it.
5. Policy Exclusions: Certain treatments or procedures may be excluded from your policy coverage. Some insurance companies may argue your situation falls under an exclusion for their own gain, so it’s important to stay familiar with your policy. 
6. Pre-Existing Conditions: While the Affordable Care Act prohibits denial of coverage for pre-existing conditions in many plans, some short-term or non-ACA-compliant plans in Florida may still impose restrictions.
7. Missed Filing Deadlines: Insurance policies often have strict deadlines for submitting claims. Missing these deadlines – or getting too close – can result in automatic denials.
8. Benefit Limits Reached: If you’ve reached the maximum benefits allowed under your policy for a specific service, additional claims may be denied.

A denied claim doesn’t mean your care isn’t important. It just means your insurer is prioritizing cost over your health. If you’re unsure how to move forward, The Nation Law Firm can review your denial and help you take the next step.

6 Steps to Take When Your Health Insurance Claim Is Denied

Having your health insurance claim denied can feel like you’ve hit a dead end, but you still have options. You can appeal their decision and, if successful, overturn it and position yourself for benefits.

Many denials happen for reasons that can be fixed, like missing paperwork, unclear medical documentation, or policy misinterpretation. If you’ve received a denial, here’s how to move forward:

1. Review the Denial Letter: Carefully read the explanation of benefits or denial notice. It should include a reason for the denial, such as lack of prior authorization, missing documentation, or a claim that the service wasn’t medically necessary.
2. Request Your Full Policy: Request your full insurance policy or plan summary. This helps you understand your benefits, exclusions, and appeal rights in clear terms, giving you a path to move forward.
3. Talk to Your Healthcare Provider: Talk to your doctor or provider about the denial. They may be able to supply additional documentation, clinical notes, or a letter of medical necessity to strengthen your case.
4. Collect Supporting Materials: Gather medical records, referrals, prescriptions, test results, and any communication documents between you and your insurer. Strong documentation can make or break your appeal.
5. Note Important Deadlines: Most plans allow 180 days from the date of denial to file an appeal, but it’s best to act sooner. Missing deadlines can cost you your right to challenge the decision.
6. Submit a Written Appeal: Your appeal should clearly explain why the treatment should be covered and include any additional documents. Make sure to send it according to your plan’s appeal instructions.

If your appeal is denied or ignored, The Nation Law Firm can help you overcome the issue with additional evidence or further legal action, if necessary.

What Is Insurance Rescission?

Insurance rescission is when your health insurer cancels your policy retroactively, usually after you file a claim. This means the insurer tries to act as if the policy never existed, so they don’t have to honor their side of the contract.

In Florida, insurers are legally allowed to rescind a health insurance policy, but only under specific conditions:

• The insurer must prove that you intentionally misrepresented or omitted material information when applying for coverage
• The misrepresentation must be directly related to the insurer’s decision to issue the policy
• You must be given written notice before rescission takes effect

Minor errors, unintentional omissions, or conditions you didn’t know about generally do not justify rescission under Florida law. However, insurers may still try to cancel a policy based on vague or outdated application questions, especially after you submit a high-cost claim.

At The Nation Law Firm, we help Florida policyholders fight wrongful rescissions and hold insurers accountable for cutting off coverage when it’s needed most. Get started today with a free case evaluation.

Filing an Appeal for Denied Treatments

Health insurance companies often deny treatment not because it’s unsafe or unnecessary, but because it doesn’t fit within their narrow definition of “standard care.” This happens especially with newer procedures, off-label prescriptions, or advanced therapies that don’t appear on outdated coverage lists.

If your claim was denied for reasons like “experimental,” “not medically necessary,” or “outside network protocol,” it doesn’t mean your care isn’t important – It just means the insurer is prioritizing cost over context.

To push back, a strong appeal should include:

• Clear medical justification from your treating physician
• Supporting documentation, such as test results, treatment plans, or peer-reviewed studies
• Expert input or second opinions when the treatment is outside traditional guidelines
• A direct response to the insurer’s stated reason for denial

When the treatment you need is time-sensitive, or the appeal feels too technical or overwhelming to manage alone, The Nation Law Firm can support you. We work with healthcare providers and medical experts to help Florida policyholders present the strongest case possible.

Coverage for Experimental or Specialized Treatments

One of the most common reasons insurers deny claims is labeling a treatment as “experimental” or “investigational.” Insurance companies often use these terms as catch-all reasons to deny coverage, even when the treatment is recommended by your doctor, supported by research, and widely used in clinical practice.

These denials commonly involve:

• New or emerging treatments not yet included in clinical guidelines
• Off-label use of medications that are FDA-approved but prescribed for a different condition
• Specialized procedures or technologies recommended by a specialist but not widely available
• Alternative care options used when traditional treatments have failed

Fortunately, you don’t have to accept their denial as final. The Nation Law Firm can help you navigate the appeals process, prepare the strongest defense, and push back against their unfair denial.

Legal Rights of Policyholders Under Florida Law

Florida law exists to protect you from unfair treatment, unreasonable delays, and denied coverage for medically necessary care.

As a policyholder in Florida, you have the right to:

1. Right to Timely Claims Processing: Insurers must process and pay claims within 20 days for electronic submissions and 40 days for paper claims. 
2. Right to a Clear Denial Explanation: Florida law requires insurers to provide a written explanation of benefits (EOB) for any denied claim. This must include the reason for the denial and how to appeal the decision.
3. Right to Appeal a Denied Claim: You have the legal right to file an internal appeal with your insurer. If that’s denied, you may request an external review by an independent third party, which is required under both Florida law and the federal Affordable Care Act (ACA).
4. Right to Protection from Bad Faith: If an insurer deliberately undervalues, denies, or delays your claim without justification, they may be acting in bad faith. You may be able to recover damages beyond your policy benefits.
5. Right to Mental Health Parity: Florida insurance plans governed by federal parity laws must provide equal coverage for mental health and substance use disorders as they do for physical health conditions.
6. Right to Fair Rescission Procedures: Insurers cannot retroactively cancel your policy without clear evidence of intentional misrepresentation, and they must follow strict notice and review procedures before doing so.
7. Right to File a Complaint: If you believe your insurer is violating your rights, you can file a formal complaint with the Florida Office of Insurance Regulation (OIR) or request assistance through the Florida Department of Financial Services Division of Consumer Services.

These protections exist to help keep you covered and hold insurers accountable. At The Nation Law Firm, we help Florida policyholders enforce their rights when insurers think they’re above the law.

Bad Faith Practices in Health Insurance

Health insurance companies have a legal duty to handle claims honestly and fairly. When they don’t, their behavior is labeled as “bad faith,” which is an actionable offense under Florida’s Unfair Insurance Trade Practices Act

Bad faith behavior includes:

• Unreasonable delays in approving treatment, processing claims, or issuing payment
• Denying coverage without proper investigation or failing to review relevant medical evidence
• Providing vague or misleading denial explanations that make it difficult to file an appeal
• Retroactively canceling your policy (rescission) after you submit a claim
• Misrepresenting policy terms to avoid paying for covered services
• Failing to respond to communications or ignoring appeal requests

If an insurance company is found guilty of bad faith practices, you have the right to pursue damages beyond your original claim. Our team can help you navigate this situation and ensure you’re seeking every dollar you’re entitled to, for no upfront costs.

How to Document Your Health Insurance Dispute

When you’re dealing with a health insurance denial or delay, documentation is your best defense. A well-documented dispute gives you leverage, shows you’re organized, and makes it harder for the insurer to avoid accountability.

Here’s what to track:

1. All Communications with Your Insurer: Keep a log of every phone call, email, and letter, including who you spoke with, the date and time, and what was discussed. Save all written correspondence, including denial letters, explanations of benefits (EOBs), and policy notices.
2. Your Insurance Policy: Request a full copy of your policy and summary of benefits. Highlight the sections related to the services in question, including exclusions, appeal rights, and definitions of medical necessity.
3. Medical Records and Doctor’s Notes: Maintain up-to-date copies of test results, diagnoses, treatment plans, and referral notes. These documents help show that your treatment is necessary and properly recommended by a doctor.
4. Appeal Documents: If you submit an appeal, keep a complete copy of what you sent, along with proof of delivery. Include your written appeal letter, supporting evidence, and any expert opinions.
5. Supporting Materials: This can include peer-reviewed studies (for newer or specialized treatments), second opinions, and professional statements from specialists that support your case.

Staying organized won’t guarantee that your insurer cooperates, but it will give you a solid foundation to move forward.

Mental Health Coverage and Parity Laws

Thanks to federal and state parity laws, most Florida health insurance plans are required to provide equal coverage for mental health and substance use disorders as they do for physical conditions. This means that your insurer cannot:

• Limit the number of covered therapy visits or inpatient days more strictly than for physical health care
• Charge higher copays or deductibles for mental health treatment
• Impose stricter prior authorization rules or referral requirements
• Deny mental health care on the basis that it’s “less necessary” or “non-critical”

However, there’s still a chance that an insurance company will try to sidestep your protections and discriminate against mental health damage. They may wrongfully deny treatment, underpay claims, or enforce hidden restrictions that violate parity rules, all of which are illegal.

If you’ve been denied coverage for therapy, psychiatric care, inpatient treatment, or medication for a mental health condition, we can help you fight back against your insurance company’s wrongful behavior. Get started today with our free case evaluation.

Legal Support for Health Insurance Disputes

You shouldn’t have to battle for coverage while you’re already battling for your health.

When an insurance company is standing in the way of the care you need, The Nation Law Firm is here to help you fight through red tape, confusing policies, or flat-out silence from the company that promised to protect you.

Since 1997, we’ve advocated for the rights of Florida residents who found themselves stuck between themselves and health insurance claim denials. Our team knows the process inside and out, giving you the upper hand as we move from step to step, together.

Don’t let an insurance company’s financial decision impact your livelihood. Complete a free case evaluation to get started.

Frequently Asked Questions

What should I do if my health insurance claim is denied?

Start by reviewing the denial letter for the reason and next steps. Then, gather your medical records, speak with your doctor, and prepare to file a written appeal within your policy’s deadline, typically within 180 days.

How can I appeal a denied health insurance claim?

You’ll need to submit a written appeal to your insurer, with supporting documents like medical records and a letter from your doctor. If the internal appeal is denied, you may request an external review by an independent third party.

What are the most common reasons health insurance companies deny claims?

Denials often happen due to lack of prior authorization, out-of-network care, administrative errors, policy exclusions, or claims that are labeled “not medically necessary.”

What is policy rescission, and how can I fight it?

Rescission is when an insurer cancels your policy retroactively, usually after a claim is filed. In Florida, it’s only legal if they can prove you intentionally misrepresented important information when first starting your policy.

Can health insurance companies deny coverage for experimental treatments?

Yes, but you can appeal if the treatment is medically necessary and supported by research or expert recommendations. Many denials labeled “experimental” are reversed with proper evidence.

What are my rights under Florida law if my health insurance company delays or denies payment?

You have the right to timely claims processing, written explanations for denials, and access to appeals. If the insurer acts in bad faith, you may also be able to recover additional compensation alongside what you’re entitled to.

How long does the appeal process for a denied health insurance claim typically take?

Insurers must respond to internal appeals within 30 to 60 days, depending on the urgency of the case. External reviews may take another 45 days, though expedited reviews are available in urgent situations.

What steps should I take to ensure my health insurance dispute is properly documented?

Keep records of all communications, denial letters, policy documents, medical records, and any appeal materials you submit.

How does mental health coverage differ from physical health coverage under insurance policies?

By law, most plans must treat mental and physical health coverage equally. However, some insurers still apply stricter limits or access barriers to mental health care, which may violate parity laws.

When should I hire an attorney to help with a health insurance dispute?

If your appeal has been denied, your policy was rescinded, or you’re facing repeated delays or underpayments, it’s time to speak with an attorney. Our team can level the playing field and help you get the coverage you’re entitled to.