Denied for a Pre-Existing Condition? Know Your Rights Under the Affordable Care Act

January 29, 2025

Take Action When Your Health Insurance Claim Is Denied

Have you received notification from your health insurance company that your claim was denied because of a pre-existing condition? If so, you are likely experiencing a host of emotions.

First, you may be frustrated.  After all, when your claim was submitted you were under the impression that your pre-existing condition was covered. Second, you may be aggravated, especially because you submitted your claim in good faith and in accordance with your plan’s requirements.  And, finally, you are likely concerned about the impact of this denial on your financial well-being.  You have already invested in your health by paying your insurance premiums in a timely manner. It is reasonable to expect your covered claims to be paid.

An insurance claim denial places the burden of the cost of treatment squarely on your shoulders.  The high cost of medical care can negatively impact your financial well-being today and well into your future.

That said, there is good news, hope in the midst of what is a devastating situation.

Consider reaching out to a health care claims attorney knowledgeable about the Affordable Care Act (ACA) and experienced in filing appeals for claims denied due to pre-existing conditions.

You see, the ACA was established for cases just like yours.  Health insurance company decisions can be appealed. The time to act is now.

Pre-Existing Conditions and the Affordable Care Act

What is a pre-existing condition?  The answer is quite simple. Any injury or illness with which you were afflicted prior to enrolling in your current insurance plan can be labeled a pre-existing condition. Examples are broad-based and range from relatively minor and temporary to incredibly serious and permanent.   Examples of common pre-existing conditions include everything from pregnancy to cancer.

Prior to 2014, care for pre-existing conditions, like the ones mentioned above, was excluded by many insurance companies, leaving individuals without coverage or unable to pursue new jobs or change careers.  One of the purposes of the Affordable Care Act was to address problems like this.  In fact, the ACA makes it illegal for health insurance companies to deny pre-existing condition coverage and impose waiting periods for coverage for them to go into effect. Additionally, their prices are regulated so those with pre-existing conditions do not face higher premium payments.

While the majority of health plans are subject to ACA guidelines, those purchased prior to March 23, 2010, may be exempt.

Common Situations Where Denials May Occur

Sadly, denials for pre-existing conditions still occur rather regularly today. Recognizing the reason for the denial is the first step in addressing it through an appeal. Some of the most common denials occur because of:

• Misunderstanding the rules set forth by the ACA
• Application errors
• Enrollment mistakes
• Specific procedural exclusions — for example, cosmetic surgery
• Employer-sponsored insurance (If your insurance is through your place of work it may be governed by ERISA; a law with specific rules and processes for appeals.).

Take time to carefully review your denial letter so you can pinpoint the exact reason for your insurance company’s refusal to pay.

What to Do if Your Claim is Denied

How you react to a denial letter can have a real impact on your future. You want to make sure you proceed carefully and correctly to increase your chances of having your appeal be successful.  Be sure to:

• Review the denial letter.  You want to understand exactly why your claim was refused.
• Gather documents. Evidence is key in developing a successful appeal. Providing clear and concise backup will strengthen your appeal. Consider including your medical records, a letter from your physician, a copy of your initial submission, as well as the denial letter, copies of your policy that outline the extent of your coverage, bills or statements from providers, and notes of your conversation with the insurance company, if there were any.
• Draft and file an appeal letter.  Crafting a clear and concise appeal letter is a critical task. You want to make sure you include all relevant information.  Appeal letters should be submitted in writing; creating a paper trail of communication is important.  Make sure you submit your appeal in the manner required by your insurance company and within the time frame allowed.  Missing deadlines can result in your appeal not being considered.

The appeals process is technical, complicated, and time consuming.   It makes sense to engage the assistance of a skilled and reputable denied health insurance claims attorney.  This professional can manage the process from beginning to end, leveraging their knowledge on your behalf. They can also handle all negotiations. Because they understand how these organizations operate, they are more successful than individuals handling the process on their own.

How Can an Attorney Help

Managing the health insurance claim appeals process can be overwhelming. Navigating the insurance world is difficult – the language is technical and processes confusing.  A seasoned legal professional can review your case and explain whether you are eligible for reimbursement under the ACA and your policy.  They will help you gather evidence, ensuring that you leave nothing out.  Additionally, they know how to write persuasive and successful appeals letters.

Quite often, insurance companies will want to negotiate a settlement. You don’t want to represent yourself in these meetings. Health care claims denial attorneys know how to approach these situations and also know what to say and what not to say.  Often, individuals themselves say things that damage their case.

Finally, if your attorney is unsuccessful in the negotiation phase, they can take your case to the next level, where they would challenge the insurance company’s decision in court.  If successful you may be awarded the compensation you were denied based on your plan as well as damages.

Protect Your Health Coverage – Engage Doug Terry Law Today

If your health care claim has been denied for a pre-existing condition, engaging the guidance of a knowledgeable and experienced attorney can make a very real difference in the outcome of your appeal.

The impact of a denied claim can be broad-based. Assuming financial responsibility for your treatment can be devastating. You want to do everything in your power to foster a successful appeal.

Doug Terry and his team have significant experience helping individuals appeal health care claim denials due to pre-existing conditions. They are well-versed in the protections provided by the ACA and understand how insurance companies operate. These attributes, combined with their commitment to providing compassionate, hands-on service, are why so many in Oklahoma reach out for help in appealing insurance company decisions. Their reputation and record for success are both outstanding.

The team at Doug Terry Law will review your policy and all correspondence from your insurance company and work with you on every step of your appeal.

A pre-existing condition should not be cause for an insurance company denial.

Contact Doug Terry Law today at 405-463-6362 to schedule a free consultation. They are ready to go to work for you right away.