My insurance denial letter doesn't make sense — what do I do?
Federal law requires denial letters to be understandable. If yours isn't, request a corrected one.
ERISA §503 + 29 CFR §2560.503-1 require denial letters to state the specific reason in a manner calculated to be understood by the participant. If yours doesn't, that's a procedural violation — and you can request a corrected notice + the specific guideline they relied on.
Steps
- Call the plan and request the specific denial reason explained in plain language
- Request the plan's specific medical-necessity criteria or rule they applied
- If the plan refuses, file a complaint with DOL/EBSA (1-866-444-3272)
- Document the procedural violation in your appeal — it strengthens your case
Frequently asked questions
My insurance denial letter doesn't make sense — what do I do?
ERISA §503 + 29 CFR §2560.503-1 require denial letters to state the specific reason in a manner calculated to be understood by the participant. If yours doesn't, that's a procedural violation — and you can request a corrected notice + the specific guideline they relied on.
What are the steps?
1. Call the plan and request the specific denial reason explained in plain language; 2. Request the plan's specific medical-necessity criteria or rule they applied; 3. If the plan refuses, file a complaint with DOL/EBSA (1-866-444-3272); 4. Document the procedural violation in your appeal — it strengthens your case
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