Denied because of a pre-existing condition

Can my insurance deny a claim because of a pre-existing condition?

It depends on the type of plan. Healthcare.gov says all Marketplace plans must cover treatment for pre-existing conditions, and that once you are enrolled a plan cannot deny you coverage or raise your rates based only on your health. It also says Medicaid and CHIP cannot refuse to cover you or charge you more because of a pre-existing condition.

Other plan types can be different. Healthcare.gov says grandfathered plans, which it describes as individual policies bought on or before March 23, 2010, do not have to cover pre-existing conditions. Short-term plans generally can exclude them. If you have a job-based plan or Medicare, check your plan documents or ask your plan or benefits office which rules apply to you.

Is a short-term plan allowed to deny me for a pre-existing condition?

Often yes. KFF explains that in states that allow short-term plans, they are medically underwritten and exclude pre-existing conditions. KFF lists California, Massachusetts, New Jersey and New York as states that bar sales of short-term plans that lack pre-existing condition protections.

KFF also says that if you file a claim, the insurer can investigate whether your condition existed before you bought the policy. That KFF article is from 2019, and state rules can change, so check your policy wording for how it defines a pre-existing condition and ask your state insurance department if you are unsure.

What if the insurance company got it wrong and my condition was not pre-existing?

This happens, and it is a good reason to appeal. You are not alone, and a denial letter is not the final word. In your appeal, ask for the exact policy wording they relied on and the records they used to decide the condition came first.

If you are on a Marketplace, Medicaid or CHIP plan, the pre-existing condition reason should not apply at all. Say so plainly in your appeal and ask them to review it again.

How do I appeal a denial for a pre-existing condition?

Healthcare.gov says you can ask your insurance company to conduct a full and fair review of its decision. The steps and time limits below come from healthcare.gov and describe the process for most private health insurance. Medicare says its appeals process varies based on the kind of coverage you have, and Medicaid has its own process too, so if you have one of those, follow the steps and deadlines on your denial letter. If your letter gives a different deadline from the ones here, go by the letter.

• Step 1: Find your deadline. Healthcare.gov says to file an internal appeal within 180 days (6 months) of receiving notice that your claim was denied. Check your letter for the deadline and mark it on your calendar.
• Step 2: Gather your papers. Collect the denial letter, any Explanation of Benefits forms, your claim number and health insurance ID number, and a letter from your doctor if you can get one. Keep notes of every phone call with the day, time, name and title of the person you talked to. Keep your originals and send copies.
• Step 3: Send a written appeal. Say the condition was not pre-existing, or that your plan type cannot deny for it. Ask for the policy wording and records they used. Keep a copy of what you send.
• Step 4: Ask for an outside review if they say no. If the insurer upholds the denial, you can request an external review by an independent reviewer. Healthcare.gov says to file within 4 months after the date you receive the insurer's notice, and that your insurer is required by law to accept the reviewer's decision.

How long does an appeal take?

For most private health insurance, healthcare.gov says an internal appeal must be completed within 30 days for a service you have not received yet, and within 60 days for a service you already received. If the case is urgent, the insurance company must speed up the process.

For an outside review, healthcare.gov says a standard decision comes no later than 45 days after the request was received, and an expedited one no later than 72 hours, or less, depending on medical urgency. Medicare and Medicaid have their own time limits, which should be on your letter.

Who makes the final decision if I disagree with my insurer?

For most private health insurance, an independent external reviewer. Healthcare.gov says external review means the insurance company no longer gets the final say over whether to pay a claim, and that the insurer is required by law to accept the reviewer's decision.

Your checklist

• Find your appeal deadline on your denial letter (healthcare.gov says 180 days from the notice for most private plans)
• Find your plan type: Marketplace, Medicaid or CHIP, grandfathered, short-term, job-based, or Medicare
• Ask your insurer in writing for the policy wording and records behind the reason
• Gather the denial letter, Explanation of Benefits, claim number and ID number
• Ask your doctor for a short letter saying what they know about when it started
• Write down every call: day, time, name, title
• Send your appeal, keep your originals, and keep a copy of what you sent

A letter you can copy

[Date] [Insurance company name] [Appeals address] Re: Appeal of denied claim Name: [Your full name] Member ID: [Health insurance ID number] Claim number: [Claim number] Date of denial letter: [Date] To whom it may concern: I am appealing the denial of the claim above. The letter says the reason was a pre-existing condition. I disagree with this decision and ask for a full and fair review. [Choose what applies: My plan type is [Marketplace / Medicaid / CHIP], which does not allow denial for a pre-existing condition. OR The condition named did not exist before my coverage began, because [short explanation].] Please send me, in writing, the exact policy language you relied on and the records you used to decide this condition came before my coverage. I have attached copies of [denial letter, Explanation of Benefits, doctor's letter]. Please reply in writing. Sincerely, [Your name] [Phone] [Address]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• My claim was denied for a billing or coding error. What do I do?
• Your claim was denied because you had no referral. Here is what you can do.
• How to read an insurance denial letter
• How to write an insurance appeal letter
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.