Health Care and Bad Faith Insurance Claims

You made the responsible decision of purchasing health insurance, even though it's expensive and you live a generally healthy lifestyle. You've been paying your monthly premiums on time and in full for years, but when you were seriously injured in a car accident and needed your medical expenses covered, your health insurance company denied your claim. Other parties may be responsible, such as the driver of the other car, but you believe the insurance company didn't properly investigate your claim before denying it.

Fortunately, you may be able to file a civil claim against the health insurance company if you can prove that it acted in bad faith.

Good Faith and Bad Faith Insurance Claims

The basic idea behind health insurance is to pay a monthly premium so that if you're injured in an accident or fall victim to an illness, those medical expenses will be covered under your policy. Unfortunately, however, things don't always run so smoothly and there are times when your claim may be denied.

While you're obligated to pay your premiums on time and in full, insurance companies are legally required to act in "good faith," which means they're not allowed to look for ways to avoid investigating your claim or paying you (per the terms of your policy). If they do engage in this type of behavior, it's known as acting in "bad faith" and the insured party has the right to file a bad faith insurance claim.

Health Care Laws: Overview

Insurance plans vary depending on a variety of factors, such as the state in which you live, the insurer, and the particular plan you choose. However, while specific benefits and coverage may vary, there are certain rights and protections provided to patients by health care laws.

Under current laws, these rights and protections include:

  • Coverage for those with pre-existing health conditions;
  • No lifetime or yearly dollar limits for coverage of essential health benefits
  • Free preventative care; and
  • More coverage options for young adults.

Filing a Bad Faith Health Insurance Claim

Sometimes it's possible to resolve your issue and get reimbursed for medical expenses by making a few calls to the health insurance company. Other times, you may be successful in winning your appeal of the denial. But, when all else fails, you may need to file a bad faith insurance claim.

While the elements of a bad faith claim will vary from state to state, a plaintiff generally has to prove the following:

  1. Benefits that were due under the insurance policy were withheld, and
  2. The reason for withholding the benefits were unreasonable.

If a person is denied health insurance coverage, it's important to be mindful of the statute of limitations for filing a bad faith insurance claim. While you may not want to resort to a lawsuit before trying other avenues - such as negotiation and/or appealing the denial - there are time limits for filing a bad faith insurance claim (which vary by state).

Recovery for a Successful Bad Faith Health Insurance Claim

The recovery for a successful bad faith health insurance claim will vary depending on state laws. Generally, however, a person who succeeds in their claim may be able to recover contract damages as well as compensatory damages. Contract damages refer to the amount of money that the plaintiff was due under the policy while compensatory damages refer to compensations for things like financial losses and pain and suffering. Sometimes, if the insurance company's actions were particularly appalling, a plaintiff may also be able to also recover punitive damages.

Need Help with a Bad Faith Health Insurance Claim? Contact an Attorney

It can be very frustrating paying your health insurance premiums in full and on time to only have the insurance company deny coverage when you need it. Luckily, you don't have to handle this issue alone. If you need help with a bad faith insurance claim related to your health insurance or have questions about health insurance laws, it's a good idea to speak with an experienced bad faith insurance lawyer near you.

Next Steps

Contact a qualified health care attorney to help navigate legal issues around your health care.

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