South Florida patients are increasingly angry with coverage denial by UnitedHealthcare — and the insurer covers 3.1 million people in the Sunshine State. 3 things to do if you’re denied

Why South Floridians are frustrated

The frustrations of South Florida residents illustrate these broader trends. CBS Miami spoke with several individuals who expressed outrage over denied claims, including Wesley William Parker.

A talented high school wrestler, Parker ranked seventh in the state last year. However, his sophomore year took a turn for the worse when he suffered a nose injury that required surgery. Despite the medical necessity, Parker says that UnitedHealthcare refused to cover the full cost of the procedure.

“Most of them had to be paid out of pocket. And it was thousands and thousands of dollars. I had to say no to the surgery … so now I just kinda have to live with it,” he told CBS Miami.

Unfortunately, Parker’s story is not unique. Federal reports cited by CBS show that UnitedHealthcare denied 33% of all claims, which is significantly higher than that of competitors like Blue Cross (22%), Aetna (22%), and Cigna (21%). These figures add to the frustration many policyholders feel, although the lack of transparency in denial rates complicates efforts to understand the scope of the problem.

UnitedHealthcare released a statement saying the company approves and pays about 90% of medical claims upon submission. They also stated that of those claims that require further review, around 0.5% are due to medical or clinical reasons.

The company called the information circulating around its treatment of insurance claims “highly inaccurate and grossly misleading.”

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What to do if your health claim has been denied

If your legitimate health care claim has been denied, it’s natural to feel frustrated and overwhelmed. However, a denial doesn’t have to be the end of the road. The KFF’s analysis revealed that in 2021, HealthCare.gov consumers only appealed in-network claim denials 0.2% of the time — and insurers ended up upholding 59% of those denials on appeal.

But you have a better chance of being one of the few who successfully appeals a denied claim if you understand the process. Start by carefully reading the denial letter from start to finish. While it's easy to get lost in the insurance and medical jargon, there are often important facts, including the reason for the denial.

According to HealthCare.gov, insurers are required to tell you the reason for the denial and how to appeal it. Identifying this reason is the first step to filing a strong appeal.

Always file an appeal, even if you think your insurer won’t approve it. Wendell Potter, a former Cigna executive turned whistleblower, told Time Magazine, “Never take ‘no’ as a final answer, ever. Insurance companies are expecting the people enrolled in their health plans to just accept whatever they decide to do because [pushing back] is complicated. It’s a burden.” Overcoming that expectation can often make all the difference.

As part of your appeal, ask for your “claim file.” This document includes all the records related to your case, which can provide valuable insights into why the claim was denied. Compare this information to national standards for your condition. If the insurer’s reasoning doesn’t align with those standards, use that as evidence to strengthen your argument.

If your initial appeal is denied, you have the right to ask for an external review, which requires a third party to review the case and make the final decision. Unlike internal appeals, external reviews are legally binding, meaning the third party’s decision is final and must be honored by the insurer.

Finally, consider contacting executives at the insurance company, posting your story on social media, or reaching out to a journalist who can bring attention to your case. According to Potter, being vocal can work in your favor. He revealed that Cigna maintained a system for handling “high-profile” cases, particularly those that caught the attention of the press. “Before too long,” he said, “that denial would be overturned.”

By understanding your rights and taking proactive steps, you can fight unfair claim denials and increase your chances of receiving the coverage you need. Remember, persistence is key, and sometimes, being the “squeaky wheel” is the most effective strategy.