My employer health plan denied my claim. Why, and is that allowed?

Health insuranceDeniedChecked Nov 6, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-06 · Source: govinfo · 45 CFR 147.136 · § 147.136(a)(1) View original ↗

In short

A plan may deny a claim, but it must tell you why in writing.
The notice must say how to appeal.
You can appeal. Do it before the deadline.

What this means

The sources do not say that a denial is always wrong, and they do not say it is always allowed. They say what the plan owes you when it denies.

For plans that are not "grandfathered" [1], the denial notice must identify the claim (date of service, provider, amount), give the denial code and what it means, explain the internal appeal and external review and how to start them, and give contact information for any consumer assistance office or ombudsman [2]. A job-based plan must also give you at least 180 days to appeal [3].

Your next step

Read the denial code and reason on your letter. If it is missing, ask the plan for it in writing. Then appeal within 180 days of receiving the notice (at least; your plan may give more).

Check it yourself

Whether the plan's reason is correct depends on your plan's own coverage terms, which these sources do not contain: "Don't know yet". Check your plan booklet. Whether your plan is grandfathered is stated in its papers.

Where this comes from (3)

[1] govinfo · 45 CFR 147.136 · § 147.136(a)(1) · checked 2026-11-06
The provisions of this section generally do not apply to coverage offered by health insurance issuers and group health plans that are grandfathered health plans, as defined under § 147.140.
[2] govinfo · 29 CFR 2590.715-2719 · § 2590.715-2719(b)(2)(ii)(E) · checked 2026-11-06
includes information sufficient to identify the claim involved (including the date of service, the health care provider, the claim amount (if applicable) … includes the denial code and its corresponding meaning … a description of available internal appeals and external review processes, including information regarding how to initiate an appeal. … disclose the availability of, and contact information for, any applicab…
[3] govinfo CFR 2024 · 29 CFR 2560.503-1 · § 2560.503-1(h)(2)(i), (h)(3)(i), (h)(4) · checked 2026-11-06
Group health plans. … (i) Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination;

How we found this

We matched your question to 3 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-06.

What we don’t know yet

Your own plan or notice may say something different. If your letter cites another rule, send it and we will look again.

Every answer is checked against the official rule it quotes.

Information only — not legal advice. Your plan, insurer or agency decides.

This answer quotes the official sources listed above, with the date we checked them. Your own policy, notice and state rules control. We are not your lawyer or your insurer. We don’t file, argue or negotiate claims for you — you send any letter or form yourself.

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