How to Sue a Health Insurance Company

When you pay your health insurance premiums every month, you do so with the expectation your insurer will always act in your best interest and be there when needed. Sadly, the past decade has shown this isn't the case, but quite the opposite. Health insurance carriers have increasingly focused their efforts on profits and not patients by turning valid policy claims into legal battles. 

It seems the new depths of deceit and unethical practices these greedy corporations stoop to are ever-increasing. So, what can you do if hurt in an accident and your insurer refuses to cover your claim? You are probably wondering how to sue a health insurance company and if you have grounds to file suit. The answer to these questions and more are best answered by an experienced insurance dispute attorney, like those at Morgan & Morgan. Read on to learn more. 

Why Suing Your Health Insurer Is Sometimes Necessary

The idea of a lawsuit when trying to recover from a serious accident is never something anyone wants to consider. But, when your insurer won't step up to the plate and protect your health and well-being according to your coverage, legal action could be your only option. All too often, these corporations try to save money by denying perfectly valid claims, misrepresenting policy language to deny part of a claim, and more.

Health insurance litigation is rarely the first step of action you will take after receiving a denial of coverage. You can expect several rounds of dispute resolution attempts before going in front of a jury. Even then, they will have a team of attorneys on hand to fight your efforts, so make sure you go in prepared and with quality representation by a health insurance dispute lawyer.

Appealing Health Coverage Decisions Before Going to Court 

Your attorney will do everything possible to find a resolution to your insurance dispute before filing a suit. This usually involves making appeals against the insurer's decisions about your claim and involves several series of reviews. In the beginning, these will only include you and your carrier, but as the denials keep occurring, an independent organization will get involved.

Internal Review Process

When your attorney files for the first internal review (appeal), they will ask the insurer to reconsider its decision involving any limit, denial, or withdrawal of your coverage. Payment disputes are also included in this process. 

To prepare your initial appeal, your attorney will gather the following: 

• Your doctor's medical opinion should support your position
• Additional statements from other doctors that back up your personal physician's opinion
• Further information about your health conditions 

If unsuccessful in reversing their initial decision, a second review can be filed. The format of this appeal may involve a committee, arbitration, or even a hearing. Personally attending isn't always required, but be prepared should it be. 

External Review Process

Should you again not successfully reverse your coverage decision, your attorney can have your doctor file an external review. How this process is conducted varies greatly because of state law and the type of health care coverage you own. If you live in a state that doesn't have a dedicated panel for these events, the Department of Health and Human Services where you live may oversee the procedure instead.
Typically, these external reviews are free or extremely low-priced. Regardless of who files it, this must be sent within sixty days since receiving the previous denial letter. 

Bringing a Lawsuit against Your Health Insurance Company

When all of your appeals have been exhausted, and you've completed an external review with no success, it may be necessary to file a suit to have your case heard in court. To do so, the following steps need to be taken: 

• Get a copy of your entire health insurance policy if you don't already have one from your provider.
• Send a written demand for a copy of the claim denial, including a detailed explanation for their rejection. Your attorney will still include a request for payment in this letter. 
• Give time for a final response to the demand for payment if your insurer makes a fair settlement offer, though unlikely.
• File for an administrative hearing. Failing to exhaust all final options before filing suit could result in a dismissal of your case. 
• With all out-of-court avenues for relief having failed, your health insurance dispute attorney will file a civil suit.

All of these steps you can take on your own, but without legal counsel already familiar with the process, you can expect the insurer to drag it out and be purposely tricky. The good news is that if the court is on your side in the matter, you can expect payment to be made promptly, though it might not arrive until the last possible moment.

Suing Your Health Insurance Company for Bad Faith Practices

According to federal law, bad faith practices are illegal and involve actions by your health insurer that go against the duty they owe you to act in good faith and deal fairly with their consumers. Examples of activities that would qualify for a bad faith suit include:

• Purposely denying legitimate claims
• Intentionally delaying payment
• Failing to respond to your claim and inquiries on time
• Misrepresenting policy language
• Not providing reasons for a denial or failure to do so promptly to subvert the appeals process
• Canceling a policy to avoid paying a claim
• Altering the provisions of a policy to manipulate a claim's validity

When your lawyer sues, they may pursue more than just the actual damages associated with your claim and ask for punitive compensation, too. To ensure you maximize the chances of winning your suit or receiving a fair settlement offer, make sure you understand how bad faith works in your state since it may have additional regulations that affect this type of case. 

Also, don't be surprised if you receive a "refund" check in the mail that includes all of your premiums and a release document. This is an attempt to cancel your policy and should be taken to your attorney. Don't sign anything and let your legal advisor handle it.

Remember, your insurer has to justify its actions regarding your claim.

How an Experienced Health Insurance Dispute Attorney Can Help

Working with a highly qualified attorney to resolve your health insurance dispute can make the difference in being successful. Your insurer has teams of lawyers working around the clock for it and will use every resource to avoid paying what you are due. So how do you fight back against a corporate giant? Unless you know the inner workings of healthcare law, you likely can't. This is why you need representation to protect your rights and best interests. 

Because state laws vary considerably, knowing how to use a health insurance company comes with a steep learning curve. Trust knowledgeable legal professionals like the attorneys at Morgan & Morgan to explain how this process works in your area and what steps need to be taken. Having someone to communicate with your insurer on your behalf can also make the entire ordeal less stressful, and you never have to worry about how to file an appeal or file paperwork. 

By choosing a firm that works on a contingency fee basis, anxiety about how you will afford legal services is also not an issue. Truly qualified attorneys will be happy only to get paid if you win your case.