Patient Refunds for Bad Denials Act of 2026

Key Points

• The bill creates civil penalties for health insurers that deny 25% or more of claims in a plan year. The government could fine companies starting at $10 million, with an extra $2 million for every percentage point above the threshold.
• Money collected from these fines would be returned directly to the people enrolled in the penalized insurer's plans on a pro rata basis, essentially acting as a refund for customers whose claims were denied at high rates.
• When an insurer denies a claim by saying a treatment was not medically necessary, the company must now give the patient its specific medical necessity standards and explain why the treatment failed to meet them.
• The government would audit insurers to check their denial rates. Claims denied for actual fraud or legitimately unnecessary treatment would not count against an insurer, but the insurer has to prove the fraud claim was valid.
• Insurers must also report their overall claims denial rates to the government each year, creating new public accountability for how often companies reject coverage requests.