Making Insurance Claims After a Diagnosis in the US

Many people discover after a diagnosis that they have insurance coverage they had forgotten about or never thought to use. Before making any changes to existing policies, check what you hold — some policies pay out on diagnosis itself, and cancelling coverage could forfeit an entitlement you didn't know existed. If you'd rather have a plan built around your situation, answer a few questions and we'll build one around you →

Types of policy to check

Life insurance — living benefits

Most people think of life insurance as paying a death benefit to beneficiaries. Many policies also include an Accelerated Death Benefit (ADB) or living benefit rider that allows the policyholder to receive a portion of the death benefit while still alive — typically when a physician certifies a terminal illness with a life expectancy of 12 to 24 months or less (the threshold varies by policy). Benefits paid under an ADB reduce the death benefit ultimately paid to beneficiaries by the amount advanced.

ADB provisions appear on term life, whole life, universal life, and variable life policies — both individually purchased and employer group policies. Contact your insurer and ask specifically about accelerated death benefit provisions; they are not always prominently described in the policy document. Payments received under an ADB are generally income-tax-free if the insured is certified as terminally ill, under IRS rules — confirm the tax treatment of any specific payment with a tax advisor.

Critical illness and specified disease insurance

Critical illness insurance (sometimes called specified disease or dread disease insurance in older policies) pays a lump sum on first diagnosis of a covered condition — regardless of your ability to work and regardless of actual medical costs. The money can be used for anything: treatment costs, lost income, mortgage payments, household expenses.

These policies are less common in the US than in some other countries, but they are sold as voluntary or supplemental benefits through many employer group plans during open enrollment, and as individual policies through agents. Check your employer's benefits portal and any supplemental coverage you may have elected — the premium is often a small payroll deduction that is easy to forget.

Covered conditions vary significantly by policy but typically include invasive cancer, heart attack (with specified diagnostic criteria), stroke (with neurological deficit persisting beyond a specified period), coronary artery bypass surgery, major organ transplant, kidney failure, and ALS. Some policies cover additional conditions such as Parkinson's disease, blindness, or coma. Review the exact list in your policy certificate before assuming you are or are not covered.

Individual disability income insurance

An individually purchased disability income policy replaces a portion of your earnings if illness prevents you from working. Unlike employer group plans, individual disability policies are portable — they remain in force regardless of whether you change employers, and cannot be cancelled by the insurer as long as you pay premiums. If you purchased a policy at any point — through an insurance agent, a professional association, or directly — locate the policy document and contact the insurer.

Employer group long-term disability

Group LTD coverage through your employer was covered in detail in the work and income guide. For this guide's purposes: check your Summary Plan Description (SPD) for claims procedures, deadlines, and appeal rights. Employer group LTD is governed by ERISA, which significantly affects your legal rights if a claim is denied.

Mortgage protection insurance

Mortgage protection insurance — sometimes arranged through a mortgage lender at the time of closing, sometimes purchased separately — may pay your monthly mortgage payments or the outstanding loan balance in the event of death, disability, or critical illness. Coverage terms vary widely. Check your mortgage closing documents, look for recurring premium payments on bank statements, and contact your mortgage lender to ask whether a protection policy was arranged in connection with the loan.

Accidental death and dismemberment (AD&D)

AD&D insurance pays a benefit if death or specific severe injuries — loss of limb, loss of sight, loss of hearing — result from an accident. It does not cover death or disability caused by illness — cancer, heart disease, stroke, organ failure, and other medical conditions are not covered. Many employer group plans include AD&D as a standard or supplemental benefit. If you have AD&D coverage, it is worth confirming you have it, but it will not provide benefits in connection with an illness diagnosis.

Employer group plans — finding what you have

Log in to your employer's HR or benefits portal (common platforms include Workday, ADP, Fidelity NetBenefits, and Benefitfocus) to see a complete list of your enrolled benefits. Not all employees track every election they made during prior open enrollment periods.

Request your Summary Plan Description (SPD) for each benefit you are enrolled in. Under ERISA, plan administrators are required to provide an SPD free of charge within 30 days of a written request. The SPD is the governing document for ERISA plans — it describes eligibility, benefit amounts, claims procedures, appeal rights, and contact information for the plan administrator. Read the claims and appeals section before filing.

Benefits that commonly appear in employer group packages beyond health insurance:

• Group term life insurance — often one times base salary provided free; supplemental multiples available as payroll deductions
• Group long-term disability — typically provided at no employee cost for a base benefit; supplemental buy-up options may be available
• Group critical illness, specified disease, or cancer insurance — voluntary benefits elected during open enrollment
• Group accident insurance — separate from AD&D; some policies cover certain illnesses or hospitalization in addition to accidents
• Group short-term disability — varies widely; some employers self-fund STD rather than purchasing insurance

When you leave employment, group life insurance policies typically include a conversion right — the right to convert your group coverage to an individual permanent life policy within 31 days of leaving employment, without medical underwriting. This preserves insurability regardless of your health status. The resulting individual policy is generally more expensive than group coverage, but it maintains coverage you might not be able to obtain on the open market after a diagnosis. Ask your HR department about conversion options before your last day.

Finding forgotten policies

Insurance policies purchased years or decades ago are easy to forget. A diagnosis is the right moment to conduct a thorough search.

• NAIC Life Insurance Policy Locator — the National Association of Insurance Commissioners offers a free online tool at eapps.naic.org/life-policy-locator that allows you to request a search of participating insurance company records. Insurers check their records and notify you if a life insurance or annuity policy is found in your name or the name of a deceased person you are searching for. This is the most efficient tool for unknown life insurance policies — use it first.
• State unclaimed property databases — life insurance death benefits that went unclaimed are eventually turned over to state governments as unclaimed property. Search for your own name (or that of a deceased family member) through your state's unclaimed property office; unclaimed.org (operated by NAUPA) links directly to each state's database.
• Bank and credit card statements — search 12–24 months of statements for recurring payments to insurance company names. Monthly premium deductions for policies you may have forgotten are the most reliable indicator of active coverage.
• Payroll stubs — look for deductions for supplemental life, critical illness, accident, or disability insurance taken directly from your paycheck rather than billed separately.
• Previous employers' HR departments — group coverage you elected at former employers may have included conversion or portability options that allowed coverage to continue after you left. Contact HR at employers you have left to find out what benefits you had and whether any conversion or porting occurred.
• Financial advisors and insurance agents — contact any advisors or agents you have worked with; they may have records of policies they arranged for you.
• Old email inboxes, paper files, and safe deposit boxes — search for insurance company names, policy numbers, and confirmation emails from enrollment or purchase.
• Mortgage documents — check closing disclosures and correspondence from your mortgage lender for evidence of mortgage protection coverage.

Critical illness insurance — how definition matching works

Receiving a qualifying diagnosis does not automatically mean a critical illness policy pays — the diagnosis must match the policy's specific definition of a covered condition. Read the definitions section of your policy certificate carefully, or ask your insurer to confirm in writing whether your condition triggers a benefit.

Cancer definitions

Most critical illness policies cover invasive cancer — cancer that has spread beyond the layer of cells where it originated. Many policies exclude non-invasive conditions, including carcinoma in situ (early-stage cancer confined to the original cell layer), some skin cancers (particularly basal cell and squamous cell carcinoma of the skin), and some low-grade tumors. If your diagnosis is an early-stage cancer or a non-invasive condition, review your policy's cancer definition carefully — the exclusion of carcinoma in situ is common and is often the source of disputed claims.

Heart attack and stroke definitions

Heart attack definitions in critical illness policies typically require meeting specific diagnostic criteria — elevation of cardiac biomarkers (such as troponin) above specified thresholds, combined with EKG changes consistent with acute myocardial infarction, and symptoms. Not all cardiac events meet the policy definition; a minor cardiac event with minimal biomarker elevation may not qualify. Stroke definitions typically require a neurological deficit persisting beyond a specified period — commonly 24 or 48 hours — and exclude transient ischemic attacks (TIAs, or "mini-strokes"), which resolve within 24 hours.

Survival period

Most US critical illness policies contain a survival period — a requirement that the insured survive a specified number of days (typically 14 to 30 days) after diagnosis before the benefit becomes payable. If the insured dies within the survival period, the critical illness benefit may not be paid — though the life insurance death benefit, if any, would still apply. Review your policy for this provision and confirm its terms with your insurer.

Pre-existing condition lookback

Critical illness policies — particularly individual policies and some group policies — typically exclude conditions for which you had symptoms, sought medical advice, or received treatment within a lookback period before coverage began, commonly 12 months. The scope of the lookback varies by policy; some are limited to conditions for which you were actually diagnosed during the lookback period, others cover conditions for which you had symptoms that a reasonable person would have sought treatment for. If your condition arguably existed before your coverage effective date, review the pre-existing condition definition closely and consider consulting an insurance attorney before accepting a denial.

Lump sum vs. reimbursement policies

Most individual critical illness policies in the US pay a fixed lump sum on qualifying diagnosis, regardless of actual medical costs. Some older or employer-provided "specified disease" policies instead reimburse actual medical expenses up to a policy maximum. These are fundamentally different: a lump-sum policy gives you cash to use however you choose; a reimbursement policy requires you to incur and document eligible expenses first. Know which type you have before expecting a particular type of payment.

Disability insurance — key provisions that determine your benefit

Definition of disability

The definition of disability in your policy is the most important provision determining when benefits are payable:

• True own-occupation — you cannot perform the material and substantial duties of your specific occupation, even if you are capable of working in another field. You can collect full disability benefits while working in a different occupation and earning income. The most favorable definition; most common in individual policies for professionals (physicians, attorneys, dentists, engineers).
• Modified own-occupation — you cannot perform the material duties of your own occupation AND you are not gainfully employed in any other occupation. You qualify for benefits only if you are not working in another capacity. A middle-ground definition.
• Any-occupation (gainful occupation) — you cannot perform the duties of any occupation for which you are reasonably suited by education, training, or experience. The most restrictive definition; standard in many group LTD policies after the own-occupation period ends (typically 24 months).

Many group LTD policies apply the own-occupation definition for the first 24 months of a claim and then shift to any-occupation. If you are approaching the 24-month mark on a claim, be prepared for a potential re-evaluation of your claim under the stricter standard, and ensure your medical documentation addresses your functional capacity relative to the any-occupation standard.

Elimination period

The elimination period (also called the waiting period) is the length of time you must be disabled before benefits begin — functioning like a deductible paid in time rather than money. Common elimination periods for individual disability policies are 30, 60, 90, 180, or 365 days. Employer STD coverage, accrued sick leave, or personal savings typically bridge the elimination period. Confirm your elimination period and coordinate it with your STD coverage so there is no gap.

Benefit period

The benefit period is how long monthly disability benefits continue if you remain disabled. Individual policy options include 1 year, 2 years, 5 years, to age 65, to age 67, or (in older policies) lifetime. For a serious diagnosis with lasting functional impact, a longer benefit period can represent the difference between financial stability and years of distress. Group LTD benefit periods are defined in the SPD.

Residual and partial disability benefits

Many individual disability policies — and some group LTD plans — include a residual or partial disability benefit that pays a proportional benefit if you can work part-time but your income is reduced by a specified percentage (commonly 20%) due to your disability. This provision is particularly valuable during active treatment, when you may be able to work reduced hours rather than being completely unable to work. Some policies require a period of total disability first before partial disability benefits begin; others pay partial disability benefits from the outset of reduced capacity. Review your policy for this provision — it may provide income during treatment even if you are not entirely unable to work.

The claim process

Notify your insurer promptly

Most insurance policies require notification of a claim within a specific period from the onset of the qualifying event — commonly 20 to 30 days for disability claims, though this varies by policy and type of insurance. Life insurance ADB claims and critical illness claims also have notification requirements. Late notice can complicate a claim and, in some cases, provide grounds for denial. Notify your insurer as soon as you believe a claim may be payable — you do not need to have all documentation assembled first.

Claim forms and the Attending Physician Statement

Once you notify the insurer, they will send claim forms. For disability and life ADB claims, these typically include a claimant statement (completed by you), an Attending Physician Statement (APS) (completed by your treating physician), and an authorization to obtain medical records.

The APS is a critical document. It asks your physician about your diagnosis, treatment, functional limitations, restrictions and limitations on activity, expected duration of disability, and prognosis. The quality and completeness of the APS significantly affects claim outcomes. Before your physician submits the form, ask to review a copy and confirm that it accurately reflects your functional capacity and the severity of your limitations. Understatement by a physician who is focused on your clinical care rather than the claims process is a common reason for initial disability denials.

Medical records and authorization

You will typically be asked to sign a medical records release authorization. The insurer will then request records directly from your treating providers. Ensure your medical records with all treating physicians are complete, consistent, and reflect your reported symptoms and functional limitations — discrepancies between what you report to your doctors and what appears in records can complicate claims. You have the right under HIPAA to obtain copies of your own medical records from any provider; do so before or alongside the insurer's request so you know what is being submitted.

Independent Medical Examination

Most disability and some life insurance policies give the insurer the right to require you to submit to an Independent Medical Examination (IME) — a one-time medical evaluation conducted by a physician hired and paid by the insurer. Despite the label "independent," IME physicians are retained and compensated by the insurance company, and their findings sometimes differ from your treating physician's assessments. You are generally required to attend an IME if requested as a condition of continued benefits. Bring documentation of your condition and functional limitations to the examination, be honest and thorough about your symptoms, and request a copy of the resulting report through your insurer after it is completed.

Keep copies of everything

Maintain a dedicated file for each insurance claim containing:

• All completed claim forms before submission (keep a copy of everything you sign and send)
• Copies of all medical records and the APS submitted with the claim
• All written correspondence from the insurer — denial letters, benefit confirmation letters, requests for additional information
• Notes of all phone calls (date, time, name of representative, what was discussed)
• Copies of all medical authorizations you signed
• Records of all benefit payments received and any offsets or deductions applied

For ERISA-governed group plans, the administrative record you build during the claim and appeal process becomes the evidentiary record if you later pursue litigation — courts reviewing ERISA claims are generally limited to reviewing what was submitted during the administrative process. This makes thorough documentation at the claims stage essential, not optional.

State insurance regulation — complaints and oversight

In the United States, insurance is regulated primarily at the state level, not federally. Each state has an insurance commissioner (or department of insurance, or similar authority) that licenses insurers and agents, regulates policy forms and rates, and handles consumer complaints. If you believe an insurer has unreasonably denied a claim, failed to respond in a timely manner, or otherwise violated insurance regulations, you can file a complaint with your state insurance department at no cost.

State insurance departments have authority to investigate complaints, require insurers to respond and justify claim decisions, and sanction insurers who violate state insurance laws. Even the act of filing a complaint can prompt reconsideration by an insurer. Find your state's insurance department through the NAIC at naic.org/state_contacts.htm.

An important exception: most employer-sponsored group plans (health, LTD, life) are governed by ERISA, a federal law, rather than state insurance law. ERISA plans are regulated by the U.S. Department of Labor — not by state insurance departments. For ERISA plan disputes, the DOL Employee Benefits Security Administration (EBSA) at 1-866-444-3272 handles complaints and inquiries. State insurance departments do not have authority over ERISA plans.

The NAIC (National Association of Insurance Commissioners) coordinates among state insurance regulators and provides consumer resources at naic.org, including guidance on understanding insurance policies and how to file complaints. The NAIC itself is not a regulator and cannot resolve individual complaints — always go to your state insurance department for complaint resolution.

Denied claims — your appeal rights

Internal appeals

If a claim is denied, you have the right to appeal. Do not simply accept a denial — a significant percentage of denied claims are reversed on appeal, particularly when additional medical evidence is submitted.

For ACA-governed health insurance (individual or small-group marketplace plans), the ACA requires insurers to provide an internal appeals process. You receive written notice of the denial with the reason; you have the right to internal appeal, typically within 180 days of the denial; the insurer must decide your appeal within 30 days for pre-service claims or 60 days for post-service claims. You may submit additional medical evidence and documentation.

For ERISA group plans (most employer-sponsored health, disability, and life plans), ERISA requires at least one internal appeal level before you can sue. The denial letter must state the reason for denial and describe your appeal rights and deadlines — read it carefully. ERISA disability plans must decide appeals within 45 days (extendable to 90 days with notice). Submit all additional medical evidence, treating physician letters, and other supporting documentation with your appeal — as noted above, this becomes your record for any future litigation.

External review

For ACA health plan denials: if your internal appeal is denied (or for urgent situations where waiting for internal appeal is not medically appropriate), you have the right to external review by an Independent Review Organization (IRO). The IRO is not affiliated with your insurer; its decision is binding on the insurer. Request external review through your state's insurance department (for state-regulated plans) or through the federal external review process (for self-insured ERISA health plans). External review decisions in your favor are enforceable.

For non-ERISA disability and life insurance claims (individually purchased policies), external review availability depends on state law — some states have enacted external review rights for these policies. Check with your state insurance department. Even without a formal external review mechanism, filing a complaint with the state insurance department can prompt independent review of the denial.

Litigation

For individually purchased policies (not ERISA), you can sue your insurer under state contract law if a claim is wrongfully denied. Most states also allow insurance bad faith claims — if an insurer unreasonably denied a valid claim or failed to properly investigate, you may be able to recover not just the policy benefit but additional damages and attorney's fees. Insurance attorneys handling individual policy claims frequently work on contingency — no fee unless you win. The statute of limitations for insurance contract claims varies by state (typically 1 to 6 years); consult an attorney before the deadline passes.

For ERISA group plan claims, litigation is more constrained. ERISA limits remedies to recovery of benefits owed and reasonable attorney's fees — punitive damages and bad faith damages are not available under federal ERISA law. Courts reviewing ERISA claim denials generally apply a deferential standard of review, evaluating whether the plan administrator's decision was arbitrary and capricious rather than conducting a fresh review. This makes thorough documentation during the administrative appeal process — including submission of all medical evidence, treating physician opinions, and vocational evidence — essential, as courts are generally limited to reviewing what was in the administrative record. Consult an ERISA attorney early; the administrative appeal record is your litigation record.

Find insurance and ERISA attorneys through your state bar association's lawyer referral service or through the American Association for Justice (justice.org).

Workers' compensation — work-caused illness only

The United States has no nationwide no-fault accident compensation scheme comparable to some other countries' systems. Two limited avenues exist for illness caused by work or third-party conduct:

Workers' compensation is a state-administered system providing wage replacement and medical benefits for employees who are injured or become ill as a result of their employment. Covered conditions include occupational diseases — illnesses caused or materially worsened by conditions at work — such as mesothelioma from asbestos exposure, lung disease from occupational dust exposure, repetitive stress injuries, and certain cancers linked to chemical exposures. Workers' comp is the exclusive remedy against your employer in most states — you generally cannot sue your employer in civil court for negligence; workers' comp replaces that right. File a claim by notifying your employer and submitting a workers' comp claim to your employer's insurer; disputes are resolved through your state's workers' compensation board or commission. Benefits typically include medical care and wage replacement (often two-thirds of average weekly wage).

Workers' compensation does not cover illness that arose independently of your employment — a cancer or heart condition with no demonstrable connection to your work is not a workers' comp claim. The work-causation requirement is strictly enforced.

Personal injury litigation: if your illness was caused by the negligence of a third party — not your employer, but a manufacturer, product distributor, property owner, or other party — you may have a civil claim for damages. Common examples include mesothelioma from asbestos-containing products manufactured or sold by third parties (separate from any employer-based workers' comp claim), pharmaceutical product liability claims, or toxic tort claims. These are complex, high-stakes cases typically handled by personal injury attorneys with experience in mass tort or toxic exposure litigation. Statutes of limitations vary by state and claim type; consult an attorney promptly after diagnosis if you have any reason to believe a third party's conduct caused or contributed to your illness.

Getting help

• State Health Insurance Assistance Program (SHIP) — every state has a SHIP providing free, unbiased Medicare counseling by trained volunteers; can help with Medicare coverage questions, Medigap comparisons, and billing disputes. Find your state SHIP at shiphelp.org.
• Patient Advocate Foundation — 1-800-532-5274 or patientadvocate.org. Free case management services for patients navigating insurance denials, prior authorization disputes, and appeal processes.
• State insurance department — file complaints about insurer conduct, get information on your rights under state law, verify insurer and agent licenses. Find your state department via naic.org/state_contacts.htm.
• DOL Employee Benefits Security Administration (EBSA) — 1-866-444-3272 or dol.gov/agencies/ebsa. ERISA plan complaints and inquiries; free advisory opinions and assistance for ERISA group plan issues.
• Insurance attorneys — handle denied life, disability, and critical illness claims for individually purchased policies; frequently work on contingency. Find through your state bar's lawyer referral service.
• ERISA attorneys — specialize in employer group plan claim disputes; essential to consult early to preserve the administrative record. Find through your state bar or the American Association for Justice.
• NAIC — naic.org. Consumer resources, state contact directory, Life Insurance Policy Locator tool (eapps.naic.org/life-policy-locator).