Why Insurance Claims Are Denied
Denials are often about contract boundaries and claim conditions, not automatically bad faith. This guide explains common denial categories in plain language.
Common denial categories
| Category | Plain-English meaning | Examples |
|---|---|---|
| Not a covered event | The policy does not cover this type of loss or service. | Excluded peril, non-covered health service, unsupported cause. |
| Exclusion applies | The policy specifically removes or limits coverage for that category. | Wear and tear, gradual damage, certain uses, non-covered services. |
| Condition not met | The policy required something that was not satisfied. | Notice timing, proof of loss, authorization, maintenance condition. |
| Documentation not sufficient | The file lacks enough support for cause, timing, ownership, value, or scope. | Missing receipts, unclear photos, unsupported estimate, coding mismatch. |
| Eligibility issue | Coverage was not active or the service/person/item was not eligible. | Lapsed policy, wrong date, wrong provider network. |
| Limit reached | Coverage exists, but the policy limit/sub-limit is exhausted or lower than expected. | Contents sub-limit, benefit maximum, deductible greater than loss. |
How to read a denial letter neutrally
Look for the stated reason, policy section, date, claim number, and whether the decision is full denial, partial denial, or request for more information. This site does not tell you what to argue; it helps you understand the category.
Health claim denial examples
Health claim denials often involve authorization, medical necessity criteria, network status, coding, eligibility, coordination of benefits, duplicate claims, or timely filing.
Property and auto denial examples
Property and auto denials often involve exclusions, cause classification, pre-existing damage, maintenance issues, lapsed coverage, use restrictions, valuation boundaries, or unsupported scope.