How to File Suit Against a Health Insurance Company

Complaints about health insurance companies refusing to provide coverage for certain procedures and medications are nothing new, but what is your recourse if it happens to you? Filing a suit against a health insurance company, even if it has refused to cover treatment a doctor has stated is medically necessary, isn’t legally possible for everyone. However, you do have a few options if you feel you were wronged by your insurance company.

Instructions

1. Contact your state insurance board. You can find information about your state board of insurance on your state government’s website. Each state has its own insurance guidelines, and your state may have rules that impact how you have to proceed with your insurance company. It may also have arbitration procedures that you can take advantage of to negotiate with your insurance company before attempting to file a lawsuit.

2. Find out if you are legally entitled to sue. Under the Employee Retirement Income Security Act (ERISA), people who receive insurance through an employer cannot recover any damages from an insurance company for a procedure that is not performed. In other words, if you get insurance through your job and the insurance company agrees to cover a heart surgery but then doesn’t pay for it, you can sue. However, if it denies coverage before the surgery–claiming it is not a necessary procedure--you cannot sue the insurer for failing to cover the surgery or any negative impacts you have from not having the procedure. This rule applies even if an insured person dies after her insurance company denies coverage for a procedure or medication that would have saved her life. Note that ERISA applies only to people who receive insurance through their employers at privately owned companies. If you are a government employee or an employee of a religious organization, or if you buy your own insurance, you can sue for withheld treatments.

3. Hire a lawyer who specializes in health care insurance cases. If you are not bound by ERISA, your lawyer can help you prepare and file your case in the proper jurisdiction (determined by where you live and your state’s insurance laws), handle negotiations with the insurance company and represent you in court should the case not be settled before it reaches that point. Insurance law is extremely complex, so it is important to hire a lawyer who specializes in this type of case. Likewise, although your state insurance board can tell you the filing procedures for your state, it is not recommended that you attempt to represent yourself in legal proceedings with an insurance company.

Tips & Warnings

• Before filing a suit against your health insurance company, read your policy carefully. There may be an internal appeals procedure you are required to follow before filing your suit. Failing to compile and follow the process may hurt your case.

• Keep organized, detailed notes of all of your dealings with the insurance company, including phone conversations. When possible, communicate in writing and keep copies of everything for your records--these communications may become important in your case.

References

• Consumer Watchdog: Health Insurer Killed a Loved One, You're Out of Luck
• Health Insurance Rates: What You Don't Know About Health Insurers
• Lawyers.com: Appeal Health Insurance Denials