Introduction: If the Doctor Says You Need It, Why Does Insurance Say No?
It’s one of the most frustrating things a patient can experience:
You see your doctor.
They recommend a test, a treatment, a specialist, or a prescription.
And then—your insurance company denies it.
You’re told it’s “not medically necessary.”
Or “not a covered benefit.”
Or “you didn’t meet criteria.”
Let me be clear: this isn’t about medicine.
It’s about money.
In this article, I’ll explain why these denials happen, how the system is designed to confuse and exhaust you, and what tools you have to fight back—including a little-known federal protection called ERISA and how to leverage your state’s Bureau of Insurance.
Denials Aren’t Personal—They’re Profitable
To understand the logic behind a denial, you need to understand how your insurance company sees you.
When your doctor bills for a visit, test, or treatment, the insurer has to pay. That payment is recorded on their books as a medical loss—because it cuts into their profit.
Let me say that again:
Your care is considered a loss on the insurance company’s financials.
The fewer services they pay for, the higher their profits.
And with most major insurers now operating as for-profit corporations, they are motivated to deny, delay, or downgrade as many claims as possible.
This isn’t conspiracy—it’s accounting.
How They Justify Denials (And Still Say They Approve “90%” of Requests)
You may hear insurers brag that they approve most prior authorizations. But here’s how the numbers actually work behind the scenes:
Let’s say 100 doctors submit prior authorization requests for MRIs or medications.
- 50% of them won’t appeal a denial. They don’t have the time.
- Of the remaining 50, another half will give up after a second denial.
- That leaves 25 who persist. After a third denial, maybe only 12 file again.
- The insurer approves 10 or 11 of those.
Now they can say they approved 90% of the final requests—while denying 90% of the original ones. That’s the game.
The System is Built to Wear You Down
Insurance companies know that most patients—and most doctors—don’t have the time, energy, or knowledge to navigate the appeal process. That’s not accidental. It’s a strategy.
- Phone lines are slow.
- Appeal instructions are vague.
- Criteria for approval are unclear.
- Forms get “lost.”
- Delays drag out until the urgency has passed.
This process is designed to make you stop fighting.
And unfortunately, in most cases, it works.
What Can You Do?
Step 1: Know Your Rights Under ERISA
Most employer-based insurance plans fall under a federal law called ERISA—the Employee Retirement Income Security Act.
Here’s why that matters:
Under ERISA, your insurer has a fiduciary duty to act in your best interest—not theirs. If they deny a medically necessary service or fail to follow proper appeal procedures, they may be violating federal law.
You can use that leverage.
When filing an appeal, cite ERISA and demand full documentation of their decision-making process. Ask for:
- The clinical criteria used
- The name and credentials of the reviewing party
- The internal guidelines used to determine your denial
- The complete appeal timeline and next steps
They’re required to respond—on the record.
Step 2: Escalate to Your State’s Bureau of Insurance
Every U.S. state has a Bureau of Insurance (or similar regulatory body). They have the authority to investigate insurance company behavior and force compliance with state and federal regulations.
If you’ve been denied a necessary treatment, especially after an appeal, you can file a formal complaint.
And here’s a tip:
When you send your insurance company a letter or email, copy the Bureau of Insurance on it. State that you’ve requested an investigation. That gets their attention.
I’ve used this strategy many times on behalf of patients. It works.
No insurer wants to be on the wrong side of a formal inquiry.
Step 3: Document Everything
Insurance companies count on the average person not tracking what was said, when it was sent, or who they spoke with.
That’s your opportunity.
Keep a log. Record:
- Dates of denial letters
- Phone calls and agent names
- Emails or letters sent
- Appeal submissions and confirmations
- Any references to ERISA or Bureau of Insurance involvement
If things escalate, your paper trail becomes your shield.
Step 4: Use Your Voice
You don’t have to be a healthcare expert to make noise.
Post on social media.
Write a letter to your local paper.
Talk to your employer’s benefits manager.
Alert other patients with the same insurer.
Insurance companies invest heavily in their public image. They don’t like being publicly accused of denying necessary care—especially when it’s true.
When to Involve Your Doctor’s Office
You’re not in this alone. Many doctors, including myself, have helped patients navigate appeals. But we’re often working with limited information—and less time.
Here’s what helps:
- Bring us every denial letter.
- Let us know if an appeal has already been filed.
- Tell us if you’ve contacted the Bureau of Insurance.
- Be patient—we’re often fighting 10 battles at once.
But if you keep the pressure on, we’ll fight with you. Insurers often pit the patient and provider against each other. They tell the patient the doctor or practice did not file the correct documents or they tell the doctor the patient no longer wants the medicine or referral. Again, it’s a strategy to save them money. You must know the rules to win the game.
Final Thoughts: Denials Are a Business Tactic—Not a Clinical Decision
If your doctor tells you something is medically necessary, and your insurance company says it’s not—it’s not a medical judgment. It’s a business tactic.
Insurance companies are masters of delay and deflection. But you have tools.
You have rights.
And you have power when you know how the system works.
Understand the game.
Keep fighting.
And hold them accountable.
About the Author
Douglas J. Jorgensen, DO, CPC, FAAO, FACOFP
Dr. Doug is a nationally recognized medical consultant, expert witness, and patient advocate. With decades of experience in healthcare policy, audit defense, and regulatory consulting, he helps individuals and providers push back against the systems that prioritize profit over patient care.
