What should a consumer do if coverage is denied by an insurer?

When a consumer's coverage is denied by an insurer, the appropriate course of action is to appeal the decision through the insurer's grievance process. This process allows the consumer to formally contest the denial and provides an opportunity to present additional information or clarify misunderstandings that may have led to the denial. Many insurance policies include a structured appeals process that outlines the steps a consumer should take to seek a reconsideration of the denial, including timelines and required documentation.

Using the grievance process is critical because it usually is the first step before further actions can be taken, such as filing formal complaints or involving regulatory bodies. Additionally, appealing gives the insurer a chance to reassess the situation, which may lead to a reversal of the denial based on the merits of the case.

While filing a complaint with the Insurance Department is an option, this typically follows the exhaustion of the internal appeals process. Accepting the denial without further action means forgoing the possibility of obtaining coverage for necessary services. Seeking alternative treatments without insurance might also lead to significant out-of-pocket expenses and does not address the issue of the denied claim. Thus, utilizing the insurer’s grievance process is the most direct and structured method to seek recourse regarding the denial of coverage.