We have successfully represented clients for many years in lawsuits against health insurance companies. Generally, people buy health insurance to protect them, financially and emotionally, in the event they have catastrophic illness. Basically, there are two types of health insurance:
Your rights may be affected depending upon whether you have an individual health insurance policy or a group health insurance policy. If you have an individual insurance policy or a group health insurance policy provided to you through your employment with a church or a state or local government, you have certain rights. Those rights include:
- Your insurance company must promptly pay your claim – generally within 30 days of receiving the claim
- Your insurance company cannot deny your claim without first conducting a fair and thorough investigation
- If your claim is denied, your insurance company must disclose the factual and legal basis for the denial
Duty of Good Faith and Fair Dealing
Your insurance company owes you a duty of good faith and fair dealing. It must treat you fair, at all times, considering its interests at least equal to the insured customer's interests. If your individual health insurance company violates its duty of good faith and fair dealing, you may hold it accountable in a court of law.
With group health insurance obtained through your employer, you have the right to expect your insurance company to treat you fairly and in good faith. However, your means to hold the insurance company accountable is likely governed by a federal law called the Employment Retirement Income Securities Act ("ERISA"). Although enacted with the idea of protecting employees, the courts have interpreted ERISA to severely restrict an individual's ability to seek redress in a court of law.
If your health insurance is subject to ERISA, you will be given an opportunity to appeal a claims denial. It is critical that you get legal advice during the appeals process. As a general rule, the only information a court will consider is the information given to the insurance company during the appeals process. If your appeal is not perfect, it is unlikely a lawsuit to get the claim paid will be successful.
Contact Us for Legal Advice
Our goal is help you understand your rights when dealing with an insurance company. If you think your insurance company is treating you unfairly, please contact us or call the office at (888) 640-0835.
May 31st, 2013
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