Disputing a decision made by your health insurance agency begins with submitting out-of-court formal complaints. Upon receiving an initial complaint, insurance companies will typically perform an internal review of the issue. This includes evaluating the original claim for errors and determining if errors were made on the part of the company.
If the first review concludes with the health insurance company refusing your appeal, you can ask for another internal review. When the second review results come back in favor of the health insurance company, a third and final appeal can be submitted. This is usually an independent examination performed by external reviewers.
When all pre-litigation appeals fail to overturn dismissal of your claim, your next step is to take the insurance company to court.
Suing Health Insurance Company Owners for Bad Faith or Denial of Claim
When a health insurance company is sued for not paying a claim or abiding by insurance policy rules, the policy holder could sue the company for bad faith.
In some cases, bad faith may rise to the level of insurance fraud. Hiring an attorney to assist in suing health insurance company administrators for bad faith is strongly recommended.
Bad faith arguments against health insurance companies include:
- Paying less than a claim is worth (ex: you have emergency surgery that literally saves your life. The hospital bills you for $50,000 but your insurance company remits only half of that because they assert the surgery was not necessary)
- Refusing or avoiding to pay a valid claim
- Denying facts that support a claim (disputing physician reports, the need for high-priced medications to treat a disease, etc)
- Delaying payment without good reason
- Ignoring attempts by you to communicate with them (emails, phone calls, faxed letters)
- Intimidating you or being extremely rude after receiving your appeal (some health insurance companies have found they may get out of paying a claim by threatening policy holders with “reverse” litigation)
- Sending you dozens of papers to fill out over an extended period of time that do nothing to advance resolution of your claim
Tips for Suing Health Insurance Company Claims Departments
When all non-litigation avenues have been taken and you don’t get the results you want, it may be time to consider obtaining legal representation.
If you decide to file a lawsuit, keep these tips in mind:
- Provide an original copy of your insurance policy, review documents, documents sent by your insurance company denying your claim and copies of emails between your and your insurance company to your attorney.
- When possible, provide dates of phone calls you made to the company should be written down, with descriptions of what was discussed during those calls.
- Never sign any documents the company may send you without consulting with your attorney.
- If the company attempts to persuade you to cancel the lawsuit, give your attorney all relevant documents you receive through email, postal mail or other methods.
Get Connected with a Lawyer Today
Health insurance companies employ a fleet of aggressive financial attorneys to fight claims they do not want to pay for one reason or another. Having an experienced attorney fight for your rights in court is essential when confronting a legally sheltered insurance company.
We can help you connect with attorneys who give free consultations and advice about filing a lawsuit against your health insurance company.