Health Insurers are Required to Provide Reasons Behind Claim Denials, Investigative Report Finds Otherwise

By Consumers for Quality Care, on December 6, 2023

A new investigative report from ProPublica highlights the unnecessary, and potentially illegal, tactics that health insurance companies use to make it difficult for consumers to obtain claim denial records.

Whenever health insurers deny coverage for medical care, they document why the denial was made, leaving a paper trail detailing what happened in each case. These records are important for consumers, especially when they appeal these denials, and federal law requires insurers to produce these records when asked for them in writing.

But ProPublica found that obtaining these records is not always easy. Some insurers provided consumers with these records only after ProPublica contact the insurers to ask why the records were not being made available. 

The report found that insurers rely on three potentially illegal methods to frustrate attempts to obtain these records:

• Claiming falsely that consumers must obtain a court order or a subpoena before the insurer can provide their claim file records;
• Labeling record requests as appeals; and
• Not providing consumers with their requests within the legally required time frame.

By falsely claiming consumers must obtain legal documentation, such as a court order or subpoena to gain access to their claim file records, insurers can face legal action.

The second method insurers use to make it difficult for consumers to obtain denied claim records is to confuse and mistake records requests for appeals. Multiple consumers reported having claim file requests incorrectly coded or tagged as an appeal, when they were simply requesting documentation explaining why their claim was denied. While appealing denied medical claims is a convoluted process and insurers have been known to deny claims that should have been covered, requesting denied claim records is a standard process that insurers must comply with.

The third method insurers will use is not providing consumers with their record requests within the expected time frame, normally within 30 days. Consumers reported UnitedHealth, Anthem, and Cigna all have failed to comply with their records request within the 30-day timeline.

CQC is deeply troubled by the tactics insurance companies use to delay providing legally required documents to consumers. We urge insurance companies to follow laws relating to consumer records, and urge all consumers to know their rights when a health insurance claim is denied.