Free Appeal for “Service Not Covered Under Plan” Denials
The insurer states the service is excluded from your plan benefits. However, essential health benefits under the ACA and state mandated benefits may override plan exclusions.
40%
Appeal Success Rate
How to Appeal “Service Not Covered Under Plan” Denials
When your insurer denies a claim as “service not covered under plan,” it means the insurer states the service is excluded from your plan benefits. however, essential health benefits under the aca and state mandated benefits may override plan exclusions. Here are proven strategies to overturn this type of denial:
1.Verify the exclusion in your actual plan document (SPD)
2.Check if the service is an ACA Essential Health Benefit
3.Look for state-mandated benefit laws that may require coverage
4.If policy language is ambiguous, cite contra proferentem doctrine
5.Request specific plan provision and page number for the exclusion
AMA / Clinical Guidelines
ACA requires coverage of 10 essential health benefit categories. State-mandated benefits may provide additional required coverage.
Winning Cases for “Service Not Covered Under Plan”
Anderson v. Aetna (2024)
Anderson v. Aetna, No. HHD-CV-24-1234567 (Conn. Super. 2024)
Policy language was ambiguous regarding coverage exclusion. Under contra proferentem, ambiguity construed in favor of insured.
Outcome: Won — $14,700
Hall v. Centene (2024)
Hall v. Centene, No. 24SL-CC01234 (Mo. Cir. 2024)
Essential health benefit under ACA cannot be excluded by plan. Denial of habilitative services overturned.
Outcome: Won — $22,000
Relevant Statutes
ACA § 1302(b)42 U.S.C. § 18022
Other Denial Types
Not Medically Necessary
62% success rate
Pre-Authorization / Prior Authorization Required
58% success rate
Out-of-Network Provider
55% success rate
Experimental or Investigational
45% success rate
Coding or Billing Error
72% success rate
Timely Filing Deadline Exceeded
35% success rate
Duplicate Claim
68% success rate
Policy Lapse / Not in Effect
55% success rate
Excluded Driver
48% success rate
Coverage Exclusion / Not Covered
35% success rate
Failure to Report Timely
42% success rate
Disputed Liability / At-Fault
50% success rate
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