Learn More: Claim Denial Rates & Plan Tiers

One way to evaluate an individual health insurance plan is by looking at how often the plan denies claims. A claim denial rate shows the percentage of medical or dental claims an insurer does not pay out of all the claims they receive from individuals and families.

Raw denial counts — The total number of claims an insurer does not pay for any reason, including missing information, administrative issues, or questions about medical necessity.

Contextual metrics — Denial rates show how often claims are rejected, but a high or low rate is only a number. It does not, by itself, show whether an insurer provides better or worse coverage.

In-Network vs. Out-of-Network Denials

Denial data is often separated based on where you received care:

In-network denial rate — Claims from doctors, hospitals, or pharmacies that have a contract with your insurance company.

Out-of-network denial rate — Claims from providers that do not have a contract with your insurance company.

Understanding Metal Tiers

When you shop for individual insurance on HealthCare.gov, plans are grouped into “metal tiers.” These tiers describe how you and the insurer share costs. They do not measure the quality of medical care.

Catastrophic — Lowest monthly premiums and very high out-of-pocket costs. These plans are meant to help with very high expenses in rare, serious situations. They are only available if you are under age 30 or qualify for a specific hardship.

Bronze — Low monthly premiums and higher costs when you get care. The plan pays about 60% of covered costs, and you pay about 40%.

Silver — Moderate premiums and moderate costs. The plan pays about 70%, and you pay about 30%.

Gold — Higher premiums and lower costs when you get care. The plan pays about 80%, and you pay about 20%.

Platinum — Highest premiums and lowest costs. The plan pays about 90%, and you pay about 10%.

Why Context Matters

When comparing personal health plans or preparing for open enrollment, historical claim denial data can provide helpful background. Knowing how often a carrier has denied in-network or out-of-network claims in your state and within your preferred plan tier offers one additional data point for comparison.

For individuals making coverage decisions, this information supports financial transparency and helps you better understand how different plans have performed in the past.

If you want to explore more data, the SeeSurance Report includes additional metrics such as Simple Loss Ratio for individual and fully insured commercial health insurance companies.

Ready to look up denial rates for your state?
Check claim denial rates by state and insurer.