Patient Refunds for Bad Denials Act of 2026

This bill aims to hold health insurance issuers accountable for excessive claims denials by establishing civil liability. It empowers the Secretary of Health and Human Services to impose substantial civil monetary penalties on issuers whose claims denial percentage for group or individual coverage reaches 25% or higher, starting January 1, 2027. The penalty structure includes a base amount of $10,000,000, with an additional $2,000,000 for each percentage point exceeding the 25% threshold.

A key provision defines the claims denial percentage based on audits, excluding claims correctly denied for fraud or lack of medical necessity, provided the issuer offers sufficient proof. Funds collected from these penalties are mandated to be distributed on a pro rata basis to individuals enrolled in the penalized issuer's plans. Furthermore, the bill introduces new consumer protections requiring issuers to provide detailed explanations for medical necessity denials, including their specific standards, and to annually report their overall claims denial rate to the Secretary, enhancing transparency in the claims process.