Imagine being told that the treatment your doctor recommends is not approved by your health insurance plan. For millions of Americans, this is not a hypothetical situation — it is a growing reality. It can be shocking and often becomes the gateway to more stress and worsening health.
In California, Senator Scott Wiener has tried to improve this situation. He authored SB 363 (Health Care Coverage: Independent Medical Review), which was co-sponsored by the CCCC, Children Now, and the Adolescent and Childhood Psychiatrists. SB 363 would have required health plans to report coverage denials or reversals to the Department of Managed Health Care (DMHC), while insurers would have reported to the Center for Data Insights and Innovation (CDI). Health plans that failed to share accurate data would have faced penalties. If more than 50% of a plan’s IMRs resulted in patients receiving the denied care, that would also have constituted a violation and led to a fine. The money collected would have been used to maintain the database and ensure accuracy. This legislation would have gone a long way toward creating a system where automatic or unreasonable denials are not tolerated.
Unfortunately, the bill died in Assembly Appropriations. Liz Helms, President & CEO of CCCC, released a statement expressing disappointment about SB 363 not passing. Please read her statement: CCCC-Statement-8.14.26 SB 363.
Health care denials occur when a health insurance company refuses to cover a medical service, procedure, test, or treatment. While insurers argue that these reviews help control costs and ensure appropriate care, patients and providers often experience denials as barriers that delay or prevent access to medically necessary care.
In California, health care denials have become a major concern for patients, providers, and advocacy organizations. Delayed treatment can worsen medical conditions, increase stress and financial hardship, and in some cases lead to serious health complications. People facing these challenges often must also cope with resulting mental health issues. Fighting denials adds to the stress. For providers, reviewing, resubmitting, and disputing denials can take time away from patient care, require additional staffing, and increase frustration and workload.
Understanding why denials occur, what rights patients have, and how to challenge an insurance company’s decision can help protect access to care. While intended to manage utilization, prior authorization requirements have become increasingly burdensome for both patients and providers.
The Growing Problem of Health Care Denials
Health care denials are not rare events. Nationally, insurers process billions of claims each year and deny a significant percentage. In a California legislative hearing this year, one health plan estimated it denied 50% of claims. Denial rates vary significantly among health plans and depend on the type of service being requested.
According to the California Department of Managed Health Care, approximately 73% of California IMR appeals result in patients ultimately receiving the requested treatment or service — a striking indication that many denied claims should likely have been approved in the first place.
California was moving in the right direction with SB 363. Requiring health plans and insurers to publicly report denials and modifications of provider‑recommended care, while imposing penalties on plans with excessive IMR overturn rates, would have been a substantive step toward improving the situation.
The lesson here is that patients who challenge denials often ultimately gain access to the care they need.