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Accidents & insurance · What to do now

Your insurance claim was denied in New York: what to do now

Updated By The editorial teamNot reviewed by an attorney — based on the official sources below

In short

A denial isn't always the final word. Read the denial letter for the specific reason and policy section, and note every deadline in it. Get a full copy of your policy and compare. Then appeal or ask the insurer to reconsider in writing, with evidence. In New York you can also file a complaint with the Department of Financial Services (DFS), which regulates insurers. For health insurance, after the plan's internal appeal you can ask DFS for an independent external appeal within 4 months. For car accident no-fault benefits, you can request arbitration. If needed, you can sue, but check the deadline: some policies shorten the time to sue.

Read on for the details, the exceptions and the sources.

In plain words

Proof of loss
The formal claim papers you give the insurer showing what happened and how much you lost.
Internal appeal
Asking the insurance company itself to review its denial.
External appeal
For health insurance: an independent reviewer, arranged through DFS, decides whether the denial was right.
DFS
The New York State Department of Financial Services, which licenses and supervises insurance companies.

Step by step

  1. Read the denial carefully

    Find the exact reason, the policy provision cited, and any deadline to appeal. Write the deadlines on your calendar.

  2. Get the full policy

    Ask the insurer for a complete copy, including endorsements. Compare the reason given with the actual wording.

  3. Ask questions in writing

    If the reason is unclear, ask the insurer to explain it and to identify the documents it relied on. Keep copies of everything.

  4. Appeal with evidence

    Send a written appeal or request for reconsideration with what fills the gap: medical records, a doctor's letter, repair estimates, photos, receipts.

  5. File a complaint with DFS

    DFS accepts complaints against insurance companies online or by mail. Include the denial letter and your policy.

  6. Use the special routes when they apply

    Health plan denials: external appeal through DFS. Car accident no-fault denials: arbitration with the American Arbitration Association.

  7. Consider court

    If the amount is small, small claims court may work; for larger claims, talk to a lawyer about a lawsuit before the policy's deadline to sue.

What to check

  • Timing: after receiving a properly executed proof of loss, an insurer must tell you within 30 working days whether it accepts or denies the claim; failing to do so without just cause, as a general business practice, is an unfair claim settlement practice (Insurance Law § 2601(a)(4)).
  • Other unfair practices listed in § 2601(a) include knowingly misrepresenting facts or policy provisions, not acknowledging your communications with reasonable promptness, and not attempting in good faith to settle claims where liability is reasonably clear. DFS can penalize insurers for each violation (§ 2601(c)).
  • Health insurance: was this a final adverse decision after the internal appeal? The external appeal clock — 4 months — starts from that decision (Insurance Law § 4914(b)(1)).
  • No-fault: did you give written notice within 30 days of the accident, and did the insurer pay or deny within 30 days of your proof of loss (§ 5106(a))?
  • Deadline to sue: contract claims generally have 6 years (CPLR § 213(2)), but your policy may set a shorter period; the standard fire policy requires suit within 24 months after the loss (§ 3404).

What you may be owed

  • If the denial was wrong under the policy, you may be owed the benefits the policy promises — that's worth checking line by line against the policy.
  • If a no-fault payment was overdue, you may be entitled to interest of 2% a month and reasonable attorney's fees for collecting it (Insurance Law § 5106(a)).
  • If an external reviewer overturns a health plan denial, the plan may have to cover the service, and the appeal fee you paid (up to $25, waived in some cases) should be returned.
  • For car damage claimed under your own collision or comprehensive coverage, the insurer may owe payment within five business days after you and the insurer agree on a settlement, under the DFS standards for auto claims.

Documents to gather

  • The denial letter and envelope or e-mail showing the date
  • Your complete policy, declarations page and endorsements
  • Your claim forms and proof of loss, and proof of when you sent them
  • Medical records, bills and doctors' letters (health and injury claims)
  • Photos, estimates, receipts and police or fire reports (property claims)
  • A log of every call: date, name, what was said

Health insurance denials

If your health plan denies a service as not medically necessary, experimental, or out-of-network, first use the plan's internal appeal. After a final adverse determination, you can submit an external appeal to DFS within 4 months. If your plan offers a second-level internal appeal, you don't have to file one — and if you do, DFS says the 4 months still run from the first appeal decision. Plans may charge $25 per appeal (no more than $75 a year), waived for Medicaid, Child Health Plus and Family Health Plus members or for hardship. Urgent cases can be expedited and decided within 72 hours (24 hours for a non-formulary drug).

When to get help

  • The claim is large (fire, major injury, long-term disability) or the insurer accuses you of fraud.
  • A deadline to sue or appeal is close.
  • Someone was seriously hurt, or there's a lawsuit against you that your insurer refuses to defend.
  • You can't get a clear reason for the denial.

Frequently asked questions

How long does an insurer have to decide my claim in New York?

Insurance Law § 2601(a)(4) says that after receiving a properly executed proof of loss, the insurer must tell you within 30 working days whether the claim is accepted or denied. No-fault benefits are overdue if not paid within 30 days after proof of the loss (§ 5106(a)).

Is there a deadline for a health insurance external appeal?

Yes: 4 months from the final adverse determination of your internal appeal, or from when the internal appeal was waived (Insurance Law § 4914(b)(1)). Providers appealing on their own behalf have 60 days.

Can DFS force the insurer to pay?

DFS investigates complaints and can penalize insurers for unfair claim practices (Insurance Law § 2601(c)). For health plans, an external appeal decision is made by an independent reviewer. For other disputes, a court or arbitration may be needed to recover payment.

How long do I have to sue my insurer?

Contract claims generally have 6 years (CPLR § 213(2)), but many policies shorten it; the standard fire policy, for example, requires suit within 24 months after the loss (Insurance Law § 3404). Check your policy's 'suit' clause.

Want your own situation checked?

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Official sources

This page was written from the sources below. “Checked” is the date the source was last opened and read.

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This page is general information based on the official sources listed, current as of the update date. It is not legal advice and does not replace a review of your own situation; if a case is already in court, a deadline is close, the amount is large, or there are criminal, immigration or family-law consequences, talk to a lawyer or legal aid.