Avoiding Denial of Benefits for Traumatic Brain Injury Claims
If you or a loved one has a TBI, you’ll need a thorough understanding of what your insurance policy covers and best practices for filing successful claims, and winning appears from denials.
Request our Free Book on Traumatic Brain Injury
An often repeated (and true) idiom about insurance policies is that “what the big print gives, the small print takes away.” The small print in insurance policies is used by health insurance companies to deny benefits and can significantly prevent access to necessary health care.
Best Practices for Avoiding Denials of Benefits or Services
The evidence is clear that insurers routinely deny benefits to cut costs, and health care claim denials are on the rise. In fact, in 2022, 42 percent of medical providers stated that claim denials were increasing; this number jumped to 77 percent in 2024. Between 2022 and 2024, medical providers also confirmed that the time it takes to be paid for treatment provided is also increasing.
Source: “State of Claims 2024: Insights from Survey Findings,” Experian Health, last accessed October 17, 2024.
Insurance companies have been known to employ computer algorithms or under-qualified people to issue denials of bundles of claims without any review of medical records; some insurance carriers are so bold they employ “denial nurses” to review claims. The fact is that the relationship between insurers and those seeking benefits is adversarial, and TBI patients and their families must be prepared to fight to get the benefits they are entitled to under their insurance policies. Insureds should not be afraid to challenge a denial. When an insurer refuses to pay for covered services, treatments, and benefits, they are in breach of the insurance policy.
Source: E. Rosenthal, “Analysis: Health Insurance Claim Denials are on the Rise, to the Detriment of Patients,” PBS News, May 28, 2023, last accessed October 18, 2024.
Many denials can be avoided, however, if individuals and their families follow the best practices for filing claims and winning appeals, as follows:
Families and health care providers must also understand and use the eligibility criteria of their insurer for each type of requested benefit, treatment, and hospitalization.
Want to learn about the benefit eligibility criteria — as well as deadlines and time limits for successfully submitting claims?
Best Practices for Winning Appeals of Denials of Benefits or Services
After a catastrophic injury, insurers anticipate that the persons with TBI (as able), their families, and their health care team will not appeal from benefit denials. Insurance companies routinely deny benefits prescribed by the treating medical providers, such as extensions of hospital stays, skilled nursing, physical therapy, speech therapy, occupational therapy, and home-care benefits. Many coverage denials are challenged successfully, yet most patients do not attempt to challenge them. In fact, the Wall Street Journal reported in 2025 that about 850 million health claims are denied each year, and less than 1 percent of patients appealed. However, up to 75 percent of appeals succeeded, and the claims were granted. When denials are appealed, and the appeal is successful, the insurer is required to provide the services or benefits. The health insurer’s claims denial process is weak, and patients must advocate for themselves. It is important to appeal and to do so promptly, especially during early treatment, when the medical services and benefits can lead to better patient outcomes.
Source: J. Wernau, “Health Insurers Deny 850 Million Claims a Year. The Few Who Appeal Often Win,” Wall Street Journal, February 12, 2025.
Appealing a denial of benefits can be complicated, and an experienced advocate or attorney may be able to help, especially if you do not understand the standard of review or the evidence needed to win your appeal. Remember the staff and social workers affiliated with the medical team should also support and assist in the appeal if they believe the treatment is necessary and helpful.
In addition, an experienced attorney can research state law to determine whether there is a basis to challenge the exclusion. Examples of invalid exclusions include ambiguous clauses (phrases, words, definitions, or terms that are unclear, vague, or inconsistent with other clauses within the policy) or an exclusion that is against state law or public policy. In some situations, the attorney may be able to claim that the insurer has acted in bad faith and violated state insurance regulations and seek damages for the denial in addition to policy benefits.
It is a sad truth that denying patient’s legitimate claims for benefits is part of the business model of some insurance companies; many insurers hope that the patients and their families will back down and not fight for benefits. As previously mentioned, just because an insurer refuses to pay a claim does not mean that the denial is legitimate or that the denial will withstand an appeal. And when insurers file weak and unjustified denials, they lose on appeal. When an insurance company issues a denial without even reading the medical records or when the standard of care clearly supports the treatment, they are wrong, but you will need to stand up for your rights.
Remember that in appeal hearings, the burden is on the health insurer to demonstrate why they are not obligated to provide the benefits or services per the insurance contract. The insurer must prove that you are not entitled to the requested benefits, treatment, or services. Even so, it is crucial to have evidence from the treating doctors to rebut any evidence offered by the insurer. You will need medical reports that establish that the treatment is medically necessary and generally accepted medical care for the condition.
Some Practical Recommendations
- Obtain a written explanation from the insurance company for the basis of any denial or nonpayment of benefit. This is important because the insurance company should be limited during the appeal to those reasons outlined in their denial letter.
- Begin preparing your appeal as soon as you receive any treatment that is not being approved. (You might receive denials early, during the first hospital admission, and you cannot wait to respond to the denial until the discharge.)
- Do not delay in filing your appeal. Check your policy for the time limits by which you must submit your appeal — typically only 30 days.
- Strictly adhere to the insurance company’s internal appeal procedures. You must follow each step in the established process, or you may give up your right to appeal under the policy terms.
- Provide copies of all relevant medical reports, records, imaging studies, and imaging reports to the appeals committee well before the hearing date. Consider compiling additional evidence, such as photographs or videos illustrating the patient’s limitations.
- Speak with treating doctors. If possible, have the treating doctor respond to the insurer’s reason for the denial and explain why the benefits are covered with reference to the policy language, why the benefits or services are necessary, the expected outcomes from treatment, and the medical consequences if the treatment is not provided. You might also ask the treating doctor if they would be willing to prepare a letter or be willing to support your case during the appeal process.
- Conduct online research for any medical studies or articles that will support the treatment denied. Submit these during the appeal process.
Were You Denied a Claim? Know Your Legal Rights
If you proceed with an appeal and it is denied, you must be prepared to take your appeal to the next level. Do not wait until the last minute. Families and medical providers should be assertive and not hesitate to file appeals. In today’s world, families, caretakers, and individuals with TBI (as able) must fight for their rights to compel insurers to live up to their obligations under the insurance policy.
All lawsuits and all private and government insurance claims and appeals must be filed within certain time limitations. Those time limits are established by law. The failure to follow these deadlines can result in an injured person losing their right to ever pursue a claim for damages or benefits or the right to appeal the denial of benefits. Injured people and their families must be aware of and abide by these deadlines.
It is essential to seek legal counsel promptly after a TBI to ensure compliance with statutes of limitations and to protect legal rights. Experienced brain injury lawyers guide individuals through the complexities of the legal system and help them navigate the claims process efficiently.
Need help investigating your legal rights related to a traumatic brain injury?
Speak to an experienced brain injury attorney team like Cohen, Placitella & Roth.
For five decades, CPR has successfully represented individuals and families in TBI cases nationwide working with qualified co-counsel.
Get Our Free Traumatic Brain Injury Book
To learn more about Traumatic Brain Injury request our comprehensive book, available for free directly to your inbox
Learn More About TBI
Traumatic Brain Injuries From Motorcycle Accidents
