When Can You Sue Your Health Insurance Company?

Your health insurance company is supposed to help you when you are sick, so why would you want to sue them? Unfortunately, insurance is a business and in order for your insurer to manage costs and make a profit, it has to deny some claims and probably employs a fleet of people to do just that.

What this means is that sometimes people do find themselves in legal showdowns with those very entities they paid for protection in a time of crisis. But there are lots of limitations on suing insurance companies, based on state laws, individual policies, and the type of insurer. And there are some steps you can take, or may have to take, before you head for court.

Insurance Denials

If you’ve been paying for insurance and are denied coverage for medical treatment for any reason, you likely feel frustrated. Stress exacerbates illness, so breathe deep and prepare to practice patience. You are not the first person to be denied on a first try. Here’s how to handle the situation.

Depending on the reason for the denial you will have to do different things, according to The Wall Street Journal. First, call the company when you are calm and talk to someone about the denial. Note the person’s name and employee identification number, if any. Request an explanation, politely, and feel free to ask questions as needed.

Administrative Options

You may learn that the issue is just a clerical error, the wrong code filled in by you or a doctor on a form, say. Or it could be more complicated.

If a treatment is considered experimental or non-traditional, try to gather evidence in the form of articles and studies that shows it is accepted and efficacious. Submit these with a letter to your insurer. Whatever the basis for the denial, try to provide proof to the contrary — for example if a treatment is deemed unnecessary, submit another doctor’s recommendation perhaps.

If efforts with your insurer yield no positive results, you turn to the state. Many states have external review boards that evaluate insurance denials administratively, but these too have limitations. Not every denial qualifies for an external review. So now it’s time to consider a lawsuit, if you didn’t already agree to arbitration when you got your policy.

Talk to a Lawyer

If you’re having problems with an insurance denial, talk to a lawyer. Your attorney can help you prepare paperwork for the external review process or even manage discussions with the insurance company. If all else fails, you will have a true ally to advise you on suing or to represent you in arbitration.

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