A new poll from the Commonwealth Fund reveals that roughly 21 percent of adults with health insurance in the United States had a medical claim or service denied by their insurer during the past 12 months. Denials were reported most often for emergency room visits, specialist appointments, and prescription medications, according to the 2025 Affordability Survey. The findings underscore ongoing frustrations with insurance coverage and the financial strain many patients face.

Key takeaways from the survey

  • One in five insured adults (21%) experienced a claim denial in the prior year.
  • Denials for emergency care and specialist visits were the most commonly reported.
  • Nearly half of those with a denial said they appealed the decision, but only about one-third of appeals were successful.
  • About 3 in 10 adults who had a denial said their health worsened as a result.
  • People with lower incomes and those in less generous health plans were more likely to report denials.

Survey scope and methods

The Commonwealth Fund fielded the 2025 Affordability Survey between January and February 2025, gathering responses from a nationally representative sample of more than 5,000 nonelderly adults ages 19 to 64. The survey asked participants about their experiences with health insurance, including whether they had been denied coverage for a medical service, treatment, or prescription drug in the past year. The report, published in partnership with SSRS, focuses on how coverage denials affect people’s access to care and their financial well being.

Common reasons for denials

Among those who reported a denial, the most frequent reasons involved claims for emergency room services, visits to specialists, and prescription drugs. Many respondents also said they were denied for diagnostic tests, imaging, or hospital stays. The report notes that prior authorization requirements were a common barrier, and denials often occurred when insurers deemed a service not medically necessary or when patients received care from out of network providers.

Impact on patients and their health

The survey found that denials had real consequences. About 3 in 10 adults who experienced a denial said their health condition got worse because they could not get the care they needed. Others delayed or skipped needed medical treatment, and some said they went to an emergency department or were hospitalized as a result of the denial. Financial strain was also common: around one in four people with a denial reported having trouble paying other medical bills or accumulating medical debt.

Who is most affected

Denial rates varied by income and insurance type. Adults with annual household incomes below $50,000 were more likely to report a denial than those with higher incomes. People enrolled in plans with narrower provider networks, such as some marketplace or employer sponsored plans, also faced higher denial rates. The report highlights that these disparities add to existing inequities in health care access and affordability.

Frequently Asked Questions

What can I do if my insurance denies a claim?

You can appeal the decision. The survey found that about half of people with a denial attempted an appeal, though only about one third of those appeals were successful. Start by contacting your insurer for a formal explanation and then file a written appeal. Many states also have independent external review processes.

Are denial rates higher for certain types of care?

Yes. The Commonwealth Fund survey indicates that denials are most common for emergency room visits, specialist consultations, and prescription drugs. Diagnostic imaging and inpatient hospital care also show higher denial rates compared to routine preventive services.

Does the type of insurance plan affect the chance of a denial?

According to the survey, people with plans that have limited provider networks or higher cost sharing are more likely to have a claim denied. Plan type matters: those in employer sponsored plans with narrow networks or marketplace plans faced higher denial rates than those with more comprehensive coverage, such as employer based PPOs or Medicaid.

This is an original report by Vital Signs Today, informed by reporting from Google News. Read the original source.

This article is for information only and is not medical advice. See our Medical Disclaimer.