My insurance company is refusing to pay for a treatment. Can I sue them or my HMO?

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Asked August 14, 2013

1 Answer

Yes, you can sue a health insurance company for denying a claim for treatment, but you must follow a specific procedure to do so legally. By law, insurance companies have time to respond to a claim, followed by an appeal from you, and then a follow up response from the insurance company. Only after you have gone through this process are you allowed to enter into legal actions against the insurer.

If your treatment is related to your employment, the Department of labor has rules which expedite care for necessary treatment. If your claim is refused by the insurance company, contact the Department of Labor and discuss the situation with a representative. The purpose here is to make sure that employees are able to get the work-related treatment they need, holding insurers to a speedier level of service.

Your insurance company has up to 90 days to respond to your initial claim. When the coverage is denied, you can file an appeal immediately, but the insurance company has another 60 days to respond again. At that time, the insurance company must provide you with a written reason for the denial and any steps you can take to get the situation resolved.

Litigation should be reserved for a last-ditch effort. The fact is, insurance companies can afford to hire the best lawyers in the field, and have the financial strength to carry a court battle for years. Your best option is to find an amicable solution that does not include a legal battle, but you do have the right to take on an insurance company if you feel it is necessary.

Answered August 14, 2013 by Anonymous

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