You Have the Right to Appeal Your Insurer’s Denial of Healthcare Services—Did You Know?

On December 4, 2024, the bustling streets of midtown Manhattan were rocked by the murder of UnitedHealthcare CEO Brian Thompson, an act that prosecutors now allege was carried out by Luigi Mangione, a 26-year-old Ivy League graduate. Mangione, arrested days later in Altoona, Pennsylvania, has pleaded not guilty to charges that include murder as an act of terrorism.

While Thompson’s death has left the corporate and healthcare world in shock, the aftermath has been equally unsettling. A vocal subset of the public has disturbingly labeled Mangione a “hero,” reflecting deep-seated anger at perceived injustices in the American healthcare system. For years, insurance companies, including UnitedHealthcare, have faced accusations of prioritizing profits over patient care, fueling resentment among those who struggle to access life-saving treatments.

Brian Thompson, 50, was widely regarded as a visionary leader in the healthcare industry, yet his tenure at UnitedHealthcare was not without controversy. Critics often accused the company of implementing practices that limited access to care, sparking lawsuits and public outcry. His death has become a flashpoint in the ongoing debate over the ethics and accountability of the U.S. healthcare system.

The polarizing response to Thompson’s murder underscores the growing tension between corporate healthcare providers and the public they serve. While Mangione’s trial unfolds, it serves as a sobering reminder of the urgent need for reform. The case highlights how systemic issues in healthcare, left unaddressed, can exacerbate societal frustrations to dangerous levels.

If you’ve ever received a denial from your health insurer, know this: you have the right to fight back. Both state and federal laws provide pathways to appeal your insurer’s decision and potentially reverse the denial of care. Here’s what you need to know to advocate for yourself or your loved ones.

Step 1: Understanding Your Right to Appeal

When an insurer denies coverage for a medical service or procedure, they are required by law to explain the reason for the denial. Common reasons include the service being deemed “not medically necessary” or “experimental.” However, these denials aren’t final, and you have the right to:

1. File an Internal Appeal: Ask your insurance company to review its decision.
2. Request an External Review: If the internal appeal fails, you can seek an independent, third-party review.

The New York State External Appeal Process

If you live in New York State and your internal appeal is denied, you can file an External Appeal through the New York State Department of Financial Services. This process allows an independent medical expert to review your insurer’s decision.

Who Can File an External Appeal?

• Individuals whose claims were denied as not medically necessary.
• Patients denied treatment for experimental or investigational reasons.
• People whose insurer refuses to cover an out-of-network service when in-network options are inadequate.

How to File:

1. Obtain the denial letter from your insurer.
2. Submit an External Appeal application within four months of the denial.
3. Pay a $25 filing fee (waived for financial hardship cases).

The decision from the external reviewer is binding, meaning the insurer must comply with the result.

The No Surprises Act (NSA), enacted in 2022, offers additional protections to patients across the U.S. The NSA addresses issues like surprise medical bills and ensures patients aren’t left footing the bill for out-of-network services in emergency situations or when treated at in-network facilities by out-of-network providers.

The No Surprises Act: Protecting Patients Nationwide

Key Protections Under the NSA:

• Insurers must cover emergency services without requiring prior authorization, regardless of whether the provider is in-network.
• Patients are only responsible for in-network cost-sharing amounts for covered services.
• Disputes about coverage or unexpected costs can be resolved through an independent dispute resolution process.

The NSA also ensures transparency, requiring insurers to provide clear explanations for denials and making it easier for consumers to challenge these decisions.

Steps to Take if Denied Coverage

1. Review the Denial Letter: Understand why your claim was denied.
2. Gather Documentation: Obtain all medical records, doctor’s notes, and evidence supporting the necessity of the service.
3. File an Internal Appeal: Contact your insurer and formally request a review. Be sure to adhere to the deadline outlined in your denial letter.
4. Escalate to an External Appeal or NSA Process: If your internal appeal is unsuccessful, file an external review with your state or through federal protections under the NSA.

Why Advocating Matters

Luigi Mangione’s story is a testament to the power of persistence. By challenging the system, he not only secured life-saving treatment for his son but also brought attention to the critical rights consumers have in healthcare. Every year, thousands of medical claims are wrongfully denied, and many patients accept these denials without realizing they have options.

By understanding your rights and taking action, you can navigate the complexities of healthcare and ensure you receive the care you deserve. As Mangione showed the world, fighting for what’s right can lead to change—not just for one person but for an entire system.

Resources to Help You Appeal Denials:

• New York State External Appeal Information: DFS Website
• No Surprises Act Help: CMS.gov
• Patient Advocacy Organizations: Groups like the Patient Advocate Foundation offer free guidance and support.

Taking control of your healthcare decisions starts with knowing your rights. If you’ve been denied, don’t give up—your path to the care you need may only be an appeal away.