If you have ever been denied a health insurance claim, the Pennsylvania Insurance Department wants you to know that you have options. Turns out, the state will take a look at your case—for free.
For Traci Wolfson of Ambridge, her prescription for a GLP-1 was a game changer. She lost 45 pounds on the drug, and her health was improving. “I just felt so good and amazing. I was eating healthy and walking a lot. And it was life-changing for me,” says Wolfson.
That was -- until the beginning of this year, when her insurance company stopped covering the drug-- saying she no longer qualified. She was told her Body Mass Index, or BMI, was no longer high enough for GLP-1 to be covered under her employer’s insurance plan. “Out of the blue. Just snap of a finger. I’m off it. And that was very devastating for me. “
Wolfson and her doctors have appealed the decision-- twice. Both times, she got a denial. And she has already started gaining weight now that she is off the drug. “It’s not right. I’m so upset over it. I really am,” says Wolfson.
Traci knew her fight against the insurance company seemed like a losing battle-- what she didn’t know was that Pennsylvania has a way for consumers to fight denials.
“The message to consumers is appeal, appeal, appeal. Don’t accept the denial if you think it should be covered under your plan,” says Pennsylvania Insurance Commissioner Michael Humphreys.
Consumers with commercial health insurance policies can request something called an Independent External Review. You can submit your denials to the Pennsylvania Insurance Department. Your claims can be submitted online here. It’s free to apply for a review.
“We are sending it out to an independent review organization that looks at the file as a whole with information the consumer, the doctors and the insurance company provided,” says Humphreys.
Since 2024-- the PID has referred 1,353 eligible cases for an external review. Of those, 655 originally denied insurance claims have been overturned. That’s almost 50 percent of denials being overturned. And once a denial is overturned, the insurance company is obligated to pay the claim.
Humphreys says very few people even appeal a denial in the first place and he wants PA consumers to know, “You don’t have to accept the insurer’s denial as the end of your story.”
Traci Wolfson says an external review is her next logical step to get the medicine she and her doctors believe should be covered.
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