The 10 Most Common Insurance Denial Reasons — And How to Beat Each One

Insurance denial letters use a small set of standard arguments to reject the vast majority of claims. Understanding each one — and knowing the specific counter-strategy — gives you a significant advantage when you appeal.

This guide covers the 10 most common insurance denial reasons across health, life, travel, home, and motor policies, with specific action steps for each.

1. Pre-Existing Condition

What the insurer says: "Your condition predated the policy start date and is therefore excluded under Clause [X]."

Why it's often challengeable:

• The condition may not have been diagnosed, symptomatic, or treated before the policy started
• The insurer may be applying the definition too broadly
• In the UK and Ireland, innocent non-disclosure doesn't entitle the insurer to void the claim entirely — only a proportionate remedy
• In Australia, APRA requires an independent medical assessment for PHI pre-existing determinations
• The specific claimed-for condition may not be the same as, or genuinely related to, the alleged pre-existing condition

How to beat it:

• Build a medical timeline with your GP and specialist showing onset, first symptoms, and first diagnosis — all post-policy
• Request the insurer's evidence and any medical examiner's report; challenge it with your own specialist opinion
• Argue that innocent non-disclosure entitles you to at minimum a proportional remedy (UK/Ireland/Malaysia)
• In Australia, request a review by an independent PHI medical examiner if you disagree with the insurer's appointed examiner's findings
• File with FOS, AFCA, FIDReC, or OFS if internal appeal fails

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2. Not Medically Necessary

What the insurer says: "This treatment/procedure/admission does not meet our definition of medical necessity."

Why it's often challengeable:

• Insurer reviewers may lack specialty expertise in your specific condition
• The clinical criteria they apply may be outdated or inconsistent with current professional guidelines
• "Medically necessary" is contractually defined — and the definition may actually cover your case
• The denial may not reflect the clinical reality as understood by your treating specialist

How to beat it:

• Get your treating specialist to write a detailed medical necessity letter referencing published clinical guidelines (NICE, ESMO, RANZCP, ASCO, MOH guidelines)
• Request a peer-to-peer review between your doctor and the insurer's clinical reviewer
• Request that the appeal reviewer holds relevant specialty expertise
• If denied again, escalate to the relevant ombudsman body — all handle medical necessity disputes

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3. Policy Exclusion

What the insurer says: "Your claim is excluded under Clause [X] of your policy."

Why it's often challengeable:

• The exclusion may be worded ambiguously — the doctrine of contra proferentem requires ambiguous terms to be interpreted against the insurer
• The exclusion may have been inadequately disclosed at point of sale (a regulatory breach)
• The facts of your claim may not actually fall within the exclusion's plain meaning
• The exclusion may be unreasonable or unfair under consumer protection laws

How to beat it:

• Read the exclusion clause precisely — does your situation actually fit the plain wording?
• If the wording is ambiguous, cite contra proferentem in your appeal letter
• If the exclusion wasn't clearly communicated when you bought the policy, raise this as a separate ground
• Under the FCA Consumer Duty (UK), material exclusions must be communicated clearly to consumers

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4. Non-Disclosure / Misrepresentation

What the insurer says: "You failed to disclose material information at application, making your policy voidable."

Why it's often challengeable:

• Under CIDRA (UK), CICA (Ireland), FSA 2013 (Malaysia), and similar laws, the remedy must be proportionate to the degree of non-disclosure
• Innocent non-disclosure does not justify voiding the entire policy
• The fact must have been material (would have changed the underwriting decision)
• The insurer must have asked a clear question about the relevant matter — general "catch-all" questions may not be sufficient

How to beat it:

• Review the original application form — what specifically was asked?
• Get medical records showing whether you knew about the relevant condition at the time of application
• Challenge materiality: would they actually have changed their underwriting decision?
• Argue proportionality under the relevant consumer insurance legislation
• File with your national ombudsman

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5. Policy Lapse or Non-Payment

What the insurer says: "Your policy was not in force at the time of the event due to non-payment of premiums."

Why it's often challengeable:

• The insurer may not have sent adequate notice before cancelling
• There may be a grace period during which the policy remained in force
• If it's a group policy, the employer (not you) may have been responsible for premium payment failures
• For mandatory insurance (health insurance in UAE, Singapore), additional protections apply

How to beat it:

• Request proof of when and how the policy lapse notice was sent
• Check whether a grace period applies — most policies have a 30-day grace period for late premiums
• If you never received lapse notice, challenge the cancellation on procedural grounds
• For employer group policies, document that premium payment was the employer's responsibility
• File with the ombudsman if the lapse was procedurally improper

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6. Failure to Notify/Report Within Required Timeframe

What the insurer says: "You did not report this claim within the [X]-day notification period."

Why it's often challengeable:

• In Australia, section 54 of the Insurance Contracts Act 1984 prevents denial solely for late notification if the delay didn't cause the insurer any prejudice
• In other markets, there may be similar proportionality arguments
• The reason for the delay may have been outside your control (hospitalisation, emergency, incapacity)
• The insurer must show the late notification caused them actual prejudice — difficulty investigating, lost evidence, etc.

How to beat it:

• Explain and document the reason for the delay
• Challenge whether the late notification actually prejudiced the insurer's ability to investigate
• In Australia, cite section 54 explicitly
• The ombudsman bodies in most countries will not uphold a denial for late notification alone if no actual prejudice resulted

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7. Fraud or Misrepresentation of the Claim

What the insurer says: "We have reason to believe this claim is fraudulent or has been materially misrepresented."

Why it's often challengeable:

• Fraud allegations require a high standard of proof
• The insurer must identify specific misrepresentations, not make general suspicion-based denials
• Minor inconsistencies in your account don't constitute fraud
• If the allegation is made publicly or communicated to third parties without adequate basis, it may constitute defamation

How to beat it:

• Request the specific basis for the fraud allegation in writing
• Provide detailed evidence and documentation addressing each alleged inconsistency
• Consider whether the allegation meets the legal standard required in your jurisdiction
• If the allegation is without foundation, a strongly worded formal complaint may prompt the insurer to withdraw it
• Legal advice may be warranted for serious fraud allegations

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8. Wear and Tear / Gradual Deterioration

What the insurer says: "The damage was caused by gradual deterioration or wear and tear, not a sudden or insured event."

Why it's often challengeable:

• Most policies cover "sudden and accidental" damage — if the damage was sudden, even if the underlying item was old, coverage may apply
• The boundary between "wear and tear" and "sudden accidental failure" is fact-specific and contested
• An independent builder's, plumber's, or engineer's report can challenge the insurer's assessor's finding
• Some insurers misapply wear and tear to reduce payments rather than deny entirely — partial applications can also be challenged

How to beat it:

• Commission an independent expert report (builder, plumber, engineer) that specifically addresses whether the damage was sudden and accidental
• Document the history of the item — if it was regularly maintained and in good condition, this counters a wear-and-tear argument
• Challenge the insurer's own assessor's credentials and methodology
• FOS (UK) and AFCA (Australia) regularly scrutinise wear-and-tear denials and overturn many

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9. Treatment at a Non-Approved Provider

What the insurer says: "You received treatment from a provider/hospital/specialist that is not on our approved list."

Why it's often challengeable:

• For emergency treatment, most policies cover any licensed provider regardless of network status
• If the insurer's approved network didn't include a suitably qualified specialist for your condition, using a non-network provider may have been reasonable
• If the insurer recently changed its network without adequate notice, treatment based on the old network should be covered
• If a GP referral directed you to a specific specialist, the insurer may have a harder time denying on network grounds

How to beat it:

• Check whether emergency provisions apply
• Document why the approved provider wasn't suitable for your specific condition
• Check whether your network changed without adequate notice
• Document the referral pathway that led you to the non-approved provider
• In Singapore, post-2025 ISP reforms include provisions about adequate panel access — check whether the insurer maintained a sufficient panel

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10. Exceeding Benefit Limits

What the insurer says: "Your annual/lifetime/per-event benefit limit has been reached, and no further claims can be paid."

Why it's often challengeable:

• The limit may have been mis-calculated (check every claim that contributed to the limit)
• Certain treatments may not count toward the limit (emergency vs. elective)
• The limit may not have been clearly disclosed when the policy was sold
• Some benefit limits are set below levels that could reasonably be expected to be sufficient — this may be a mis-selling issue

How to beat it:

• Request a full itemised account of every payment and charge that contributed to the limit
• Check whether any items were improperly charged against the limit
• If the limit was inadequately disclosed at the point of sale and the policy doesn't represent reasonable value for money, this may be a mis-selling complaint to the relevant regulator
• FCA Consumer Duty (UK) requires that products provide fair value — a benefit limit that is routinely exhausted before the end of the year may raise fair value questions

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General Strategies That Apply to Every Denial

Regardless of which reason applies to your situation:

Always get the denial in full writing. Verbal denials don't trigger regulatory timelines and can't be challenged effectively.

Always file a formal internal complaint. The complaint must be in writing and clearly labelled as a formal complaint.

Always escalate if the internal complaint fails. The free, independent ombudsman bodies in every major insurance market — FOS (UK), AFCA (Australia), FIDReC (Singapore), OFS (Malaysia), FSPO (Ireland), ICCB (Hong Kong) — have real power and regularly overturn unfair denials.

Always gather expert evidence. Whether that's a doctor's letter, an independent engineer's report, or clinical guidelines, evidence wins appeals.

Getting Help with Your Appeal

ClaimBack (claimback.app) generates professional insurance appeal letters tailored to any of the 10 denial reasons above. Answer a few questions about your specific situation and get a structured, evidence-referenced appeal letter ready to send — for free, in minutes.

Summary

Every insurance denial falls into one of a small number of categories — and every category has proven counter-strategies. The key is identifying exactly which argument your insurer is making, gathering the right evidence to challenge it, and using the regulatory infrastructure in your country to get an independent review if the insurer won't back down.