My health plan says I don't have coverage for something, but my summary of benefits says I do. What can I do?

Health insuranceDeniedChecked Nov 7, 2026

From K.Actuary, founded by Sangmin Kwon, ASA · sources checked 2026-11-07 · Source: HealthCare.gov · How to appeal an insurance company decision View original ↗

In short

Ask the plan for the reason and the plan rule it used.
You can get copies of your claim papers for free.
Appeal within 180 days. Then you can ask for an outside review.

What this means

Insurers have to tell you why they denied your claim and how you can dispute it [1]. For a job-based plan, the denial notice must give the specific reason and point to the plan rule it used [2]. You can also ask, free of charge, for copies of the papers and records about your claim [3]. Compare that rule with the page in your summary of benefits.

You must file an internal appeal within 180 days (6 months) of getting the denial notice [4]. You can send anything you want the plan to consider, such as a letter from your doctor [5].

If the plan still says no, you can ask for an external review. You must ask in writing within 4 months after the final notice [6]. The insurer must accept the outside reviewer's decision [7]. A standard review is decided no later than 45 days after the request [8]. Your state may run its own review process, and rules in your state may differ [9].

Your next step

Ask the plan for the reason, the plan rule it used, and your claim file [2] [3]. File the internal appeal within 180 days of the denial notice [4]. Send the summary of benefits page and a letter from your doctor with it [5].

Check it yourself

Read the denial letter or Explanation of Benefits for the appeal steps. Find the same service in your full plan document, not only the summary. What happens when the summary and the full plan document say different things is not in these sources — "Don't know yet". Rules in your state may differ. Ask your state insurance department.

Where this comes from (9)

[1] HealthCare.gov · How to appeal an insurance company decision · checked 2026-11-07
Insurers have to tell you why they’ve denied your claim or ended your coverage. And they have to let you know how you can dispute their decisions.
[2] eCFR · 29 CFR 2560.503-1 · § 2560.503-1(g)(1)(i)-(ii) · checked 2026-11-07
The specific reason or reasons for the adverse determination; … Reference to the specific plan provisions on which the determination is based;
[3] eCFR · 29 CFR 2560.503-1 · § 2560.503-1(h)(2)(iii) · checked 2026-11-07
Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits.
[4] HealthCare.gov · Internal appeals · checked 2026-11-07
You must file your internal appeal within 180 days (6 months) of receiving notice that your claim was denied.
[5] HealthCare.gov · Internal appeals · checked 2026-11-07
information that you want the insurer to consider, such as a letter from the doctor.
[6] HealthCare.gov · External review · checked 2026-11-07
You must file a written request for an external review within 4 months after the date you receive a notice or final determination from your insurer that your claim has been denied.
[7] HealthCare.gov · External review · checked 2026-11-07
Your insurer is required by law to accept the external reviewer’s decision.
[8] HealthCare.gov · External review · How long does external review take? · checked 2026-11-07
Standard external reviews are decided as soon as possible — no later than 45 days after the request was received.
[9] HealthCare.gov · External review · What are my rights in an external review? · checked 2026-11-07
Your state may have an external review process that meets or goes beyond these standards.

How we found this

We matched your question to 9 official sources, quoted the exact lines, and re-checked each quote against its source on 2026-11-07.

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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