US insurer claim denials delay cancer diagnosis, highlighting systemic healthcare risks
A stage 4 lung cancer diagnosis was two years late after an insurer rejected a critical PET scan, reflecting broader trends where denial rates disproportionately impact lower-income patients and drive medical bankruptcy.
Rebecca Payette, a Virginia resident, was diagnosed with stage 4 metastatic adenocarcinoma after her health insurer denied a critical PET scan two years prior to the diagnosis. The denial delayed her diagnosis, with doctors initially attributing her constant fatigue to COVID-19 despite her never testing positive. Payette now travels nearly two hours weekly from Virginia to North Carolina for treatment. Without treatment, doctors estimated she had approximately two years to live.
The U.S. has the highest health spending in the industrialised world but experiences some of the worst health outcomes. A 2025 report from the Peterson Center on Healthcare and KFF projected Americans would spend $5.6 trillion on healthcare in the year, with figures potentially reaching $8.6 trillion by 2033. In 2023, health insurance exchange carriers rejected nearly one-in-five in-network claims and 37% of out-of-network claims. Denial rates were higher for marketplace insurance compared to Medicare or Medicaid.
Common reasons for denial include reaching benefit limits, exclusions, or procedures being deemed investigational or experimental. Doctors are often required to perform "peer to peer" reviews to justify treatments, which can be challenging if insurance representatives are inexperienced. The median out-of-pocket bill for denied claims is roughly $630 per service. A 2024 study found patients earning $30,000 or less annually were 43% more likely to have preventative care claims denied than higher-income individuals.
Payette stated that her doctor fixed up the referral for the scan, but the insurance company denied it, citing that the lung lesion was not big enough. She allowed the matter to go unresolved for a year until another doctor approved the scan, leading to the cancer diagnosis. Payette expressed feeling that the denial effectively "signed her death certificate."
Patients have the right to appeal denials, request external reviews, or file complaints with state insurance commissioners. Medical bills are a leading cause of bankruptcy in the U.S. The case highlights broader issues in the US healthcare system, including high costs, fragmented insurance coverage, and rising claim denial rates, which disproportionately affect lower-income patients.
