Paying for health insurance entitles the holder to some benefits and protections as a policy holder. First, if a policy holder files a claim or requests service they are entitled to a response or investigation and if the claim is falls within the policy, it will be covered under their company. If these benefits are not provided, the policy holder may be entitled to money damages. But you will need to hire a lawyer to bring a lawsuit against the company and have the necessary evidence.
If a claim or request is denied by the insurance provider the policy holder will receive a letter notifying them of this. The letter will contain a denial of the claim or request followed by a reason for the denial and perhaps some details on the denial. Reasons a claim might be rejected are that the care is not covered by the plan, the care was administered by a provider not covered by the plan, or that the claim was the result of a pre-existing condition. If the policy holder receives such a letter and disagrees with the denial, the policy holder should begin to compile the necessary evidence to support an appeal.
To bring a case against an insurance provider as a policy holder, the holder will need a copy of their policy in the form it was at the time the claim was filed. Everything in a case with an insurance company is based on the policy between the holder and the company.
The holder will also need copies of all correspondence between them and the insurance company. This includes all forms, letters, and mailings sent to and received from the insurance company.
Many states, insurance companies, and laws may require the policy holder to file appeals before pursuing a lawsuit. Many insurance companies have internal appeal procedures that must be followed. Most states have an appeals process also through the state insurance board. If these appeals have been denied or not satisfactorily resolved, the policy holder should have copies of all the paperwork that accompanies them.
Each step of the way from the insurer’s opinion to the lawsuit has its own timeline. Under US law, the policy holder must file their first appeal within six months of the initial denial of care. Some companies allow for second, or even third, appeals if the first appeal does not result in benefit to the policy holder.
Once the policy holder has exhausted all internal appeals, the policy holder may seek an external appeal. These appeals are done either through a state government or the federal government. Each state has their own timeline for an external appeal, usually requiring it be filed within a few months of the final denial from the insurance provider.
If external appeal also does not give you the result you want, the policy holder may pursue legal action in the courts. The deadline for pursuing a lawsuit depends on your state, and while some can be a year or more, others can be limited to 30 or 60 days.
These paperwork and records are the primary pieces of evidence needed to bring a lawsuit against a health insurance company. If you feel you have not received the benefits you are entitled to under your health insurance plan, contact a local lawyer today.
Last Modified: 01-27-2017 11:58 AM PSTLaw Library Disclaimer
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