I’m 72 and my health insurance is denying my hip surgery — even with proof that I need it. What can I do now?

When United Healthcare CEO Brian Thompson was killed in New York City in early December, it sparked a range of reactions. Many were quick to point out that Americans are fed up with health insurers and their tendency to deny claims — despite this idea being taken to a tragic extreme.

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Of course, the fact that health insurance companies often deny claims isn’t a new concept. You may find yourself in a situation where you need a critical procedure, such as a hip replacement, only to be told that you aren’t eligible, even though your doctor provided the proper referrals for your condition.

In that situation, you may have an uphill battle to fight. But that doesn’t mean you’re out of luck.

It can be difficult to get a comprehensive read on the denial rates of all insurers. But the Kaiser Family Foundation (KFF) reported that among Healthcare.gov insurers with complete, accurate data, nearly 17% of all in-network health insurance claims were denied in 2021. Though this may not sound too high, the explanations for the denials were lacking.

While about 14% of those denied claims were rejected based on the service being excluded from coverage, only 2% were denied based on medical necessity. The majority — 77% — were filed under the “all other reasons” category.

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Meanwhile, in a 2023 KFF survey, 18% of insured adults said they had a claim denied within the last year that they thought would be processed. KFF also found that people who use more health services are more likely to have claims denied.

Among patients who had more than 10 provider visits in the last year, 27% had a claim denied by their insurer. But for patients who visited a provider less than three times within a year, the denial rate was only 14%.

Those with Medicare Advantage plans experience their own barriers to proper healthcare. KFF says that 99% of Medicare Advantage enrollees must obtain prior authorization for certain high-cost services to make sure they’re medically necessary. When it comes to denials, insurers either fully or partially denied 3.4 million prior authorization requests, or 7.4% in 2022 — up from 5.8% in 2021.

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