Policyholders and insurance companies have a special relationship that involves trust and certain obligations from both parties. First and foremost, insurance companies and policyholders enter an agreement where the policyholder is obligated to pay insurance fees on a periodical basis. On the other hand, the insurance company has the obligation to uphold the provisions of the insurance contract. Often those provisions include the obligation to cover costs for health treatments and the obligation to work with policyholders whenever a claim is made. When health insurance companies do not uphold their promises to the policyholder without a proper reason, then they may be required to pay for damages. 

When insurance companies fail to uphold the provisions of the contract there are multiple outcomes that can occur. First and foremost, the policyholder finds him or herself between a rock and a hard place. The policyholder must find a way to pay for the health insurance bill one way or another. Some policyholders with serious and costly health concerns find themselves applying for a second mortgage, for a loan, or find themselves having to ask family members for loaned money. Additionally, when a policyholder is unable to come up with the amount of money required to pay for the medical bill, he or she may find their health conditioning worsening which may lead to other health concerns. Health insurance companies that fail to uphold the provisions of the contract may cause damages to those insured under their contracts. Policyholders whose health condition worsens due to a bad faith practice may claim damages in a courtroom that will cover the cost of the original treatment and may cover additional costs.

A health insurance denial that was done so in bad faith that resulted in mental or physical injuries may result in a courtroom hearing where the plaintiff can seek for payments from the insurance company. Health insurance companies may be required to pay for damages whenever the denial to cover a claim was done so with malicious purposes or done so in bad faith. If the plaintiff successfully proves that the coverage denial was done so in bad faith and with malicious purposes, then the insurance company will be required to pay for damages. Damages can include a certain amount of money to cover medical bills and other expenses that were brought upon by the denial for coverage. Damages can also include costs paid to lawyers or other third parties that help challenge the case in a courtroom.  

If you are living in the United States, it is crucial to understand that a health insurance agreement is governed by laws that require both parties to uphold the agreement. In this case, when the insurance company fails to uphold their promises to the policyholder, they may be held accountable in a courtroom. Health insurance denials occur more frequently than you may think. However, when health insurances fail to uphold their promises, many choose to pay for the medical cost themselves instead of seeking legal action. Most times this is because policyholders do not know their rights under the law.

If you are denied health coverage and you suspect that the denial for coverage had no real reason, then you are encouraged to speak with an outside party about your case. Third parties such as lawyers and other agents may help you challenge the insurance company in a courtroom so that you receive the coverage and treatment that was promised to you through a lawful agreement.

United States citizens who have been denied health coverage may speak with a lawyer about their case to learn if there is anything that can be done to help their case. To speak with a local lawyer about your case, you may reach the Stop Health Insurance Denials at 310-695-5241. We are experienced with health care denial claims and can challenge the case in a courtroom. Do not let yourself be tricked by your insurance company into thinking there is nothing you can do to help your case.

Rights of the Insured

Health insurance companies like other business entities exist in a business world where they are required to turn a profit. Despite the dog eat dog world, insurance companies owe their policyholders a certain amount of legal duties. In fact, if you live in the States you will find that insurance companies are required to abide by some of the most strict insurance laws. The different policies and laws that guide insurance companies explain how insurance companies should work with their policyholders. This includes the obligation to act in good faith. Additionally, they explain ways in which insurance companies may be held responsible in a courtroom whenever they fail to uphold their legal duties. If your insurance company fails to uphold the following legal duties, you have reason enough to speak with a third party about your insurance providers failure to uphold their responsibilities.

When the following rights are violated, the insured may seek remedies otherwise known as damages. Some of these legal duties include:

The Obligation to Respond: Insurance companies have the responsibility to respond honestly and promptly to a claim you submit. By law, the insurance companies have no more than fifteen days to respond to your claims. One of the best ways to prove that a company has taken more time than is warranted to respond to your claim is by sending emails and letters to the insurance company. E-mails and letters are dated which means they can show the time it took an insurance company to respond to the claim. Furthermore, the fifteen-day policy applies to any requests or questions made to the insurance company. Like when filing a claim, the insurance company has the obligation to respond to your email or letter within fifteen days. If your insurance company is not responding to your case in an appropriate amount of time it may be an indicator that they are dragging your case on purpose.

Good Faith: Insurance companies owe their policyholders above all to be treated with good faith. Good faith includes a variety of obligations that include cooperative responses to claims, an honest review of a claim, and the obligation to explain the insurance policy in clear English. Additionally, good faith practices include the obligation to provide insurance to all individuals regardless of their race, age, national origin, physical disability, and sexual orientation. Furthermore, good faith practices include upholding the provisions of an agreement. If an insurance company says that they will cover up to a certain amount of a cost, they are required by law to cover that cost unless there is a specific and valid reason. When it comes to good faith practices there are a number of duties that an insurance company owes to its policy holders. When an insurance company acts in bad faith, it is reason enough to seek legal assistance.

Fair Claims Process: An insurance company cannot try to stall your case by requesting additional documents that reflect information that has already been provided. In some cases, insurance companies request additional documents or may restart your case with attempts to prolong your case. As with every insurance claim, the statute of limitations is the time in which you may receive coverage for a claim and/or file a lawsuit. After the statute of limitations, there is very little that the policyholder may do to keep the insurance company accountable for their actions.

Full Cooperation: Claims that are submitted to the insurance companies require certain documents and information. When it comes to these claims, it is the responsibility of the policyholder to provide their full cooperation to help advance the case. The policyholder is required to submit documents and other legal documents to help push the case. On the other hand, the insurance company is required to provide honest cooperation which means they may not use harassing tactics or request unreasonable documents during the investigation of a claim. Additionally, whenever an insurance company denies a request, they are required to fully investigate the case and provide a factual reason as to why the claim is being denied. In other words, insurance claims cannot be denied without specific information regarding the case and without showing that there has been a proper investigation regarding the facts of the case.

Required to pay for reasonable claims: When you make a claim to your insurance company and you know that you are well within the guidelines of your agreement it means your insurance company is required to pay for the claim in the amount specified in your contract. Insurance companies may not provide less than they said they would provide in the original agreement. Additionally, an insurance company may not try to coerce the policyholder to accept a lower claim that they had promised in the insurance agreement. Insurance companies are required to uphold the provisions of the insurance agreement which means they are required to pay for costs they include in their insurance agreement.

If you feel that your rights as a policyholder have been violated it is in your best interest to contact a local attorney to discuss your case. When these policies have been violated, the policyholder may seek damages that cover the original cost of the claim and may also receive other payments whenever the denial to coverage has resulted in other personal damages. To learn how to challenge an insurance company in a courtroom, you may contact a local attorney.

Damages Claims

In the state of California, the types of damages (remedies) that a policyholder may seek will highly depend on their insurance policy. It is crucial to understand that there are two types of insurance policies. There are insurance plans obtained through the public sector that are governed by state laws and there are those (insured and self-insured) programs governed by the federal government. In other words, there are some health insurance plans governed by the state and others that are governed by the Employee Retirement Income Security Act (ERISA). Since 1974, the Employee Retirement Income Security Act (ERISA) has limited the amount of power that a state has over enforcing domestic laws on private sector employee benefits.

When talking about damages, domestic laws allow the policyholder a variety of damages claims. Insurances governed by ERISA allow the policyholder to seek damages, however, they may only receive the benefits that were originally denied. This means that if you suffered economic losses or suffered from mental or physical damages, you may not be able to claim payment for your losses. With ERISA the most you claim is the original benefits that were denied and maybe payment for your attorney fees. On the other hand, if your insurance policy is governed by the state, you may seek damages for economic losses or mental damages that may have been caused by the decisions made by the insurance company.

Types of Damages

Exceptional Damages: When an insurance company denies a claim and the policy can prove that the insurance company has acted in bad faith, the insurance company will be required to cover the original costs of the treatment. However, when the denial for coverage results in additional more costly procedures, the judge may mandate the insurance company to cover the costs. This is true even if the cost is more than the amount the original claim. For instance, if you suffer an injury or your health worsens due to the delay in insurance coverage and now the bill has doubled, the insurance company may be required to pay for the total cost despite the fact that it is not mentioned in the original contract. Furthermore, if the insured is obligated to seek lawyer assistance to uphold the provisions of a legal agreement, the insurance company may be required to pay for the lawyer fees. These types of damages can only be claimed if the individual’s health insurance is governed by the state. 

Punitive Damages: A policyholder may seek punitive damages whenever an insurance company acts in bad faith. Unlike the special damages mentioned above, punitive damages are meant to punish the insurance company for failing to uphold the provisions of the contract. Punitive damages are usually capped at a quarter of a million dollars; however, if the jury finds that the insurance company acted with the intent to cause harm, then the damages may be uncapped. Punitive damages are meant to dissuade the insurance company from acting in a negligent manner in the future. For a policyholder to claim punitive damages, the policyholder will have the burden to provide convincing evidence that proves the insurance company acted with malice, negligence, and acted with indifference to consequences. Furthermore, to seek claims higher than a quarter of a million dollars, the policyholder will be required to prove that the insurance company acted with clear intentions to cause harm to the policyholder. To learn more about punitive damages in the damages that can be claimed in your state, you are encouraged to speak to a local law expert about your case.  

Lawyer Fees: as mentioned earlier when a policy is obligated to seek legal assistance to uphold the provisions of a legally binding insurance agreement, the costs paid to the lawyer may be by the insurance company. In other words, the damages paid through a court order may include lawyer fees as part of the damages claims.

Regardless of whether your insurance company is administered by ERISA or the state of California, it is crucial to understand that the policyholder has rights to challenge their insurance company in a courtroom. Despite the differences in administration, the policyholder has the right to claim benefits that include coverage for the benefits that were originally denied. In both cases, the policyholder has the responsibility to present the facts of their case proving that the insurance company acted with malice or with negligence. If you have been denied coverage and you wish to learn about ways in which you can challenge the insurance company in a courtroom, you may contact a local attorney today.   

Find an Insurance Claim Damages Attorney Near Me

The fact is that insurance companies deny coverage on a daily basis in order to save a buck. Insurance companies are required to turn a profit which is a huge factor contributing to the denial of coverage. However, state laws mandate that insurance companies work in an honest manner upholding them to the policies of their contractual agreements. In other words, when an insurance company promises coverage for certain costs, they are required to come through with payment. This is true whenever your claims are well within the provisions of your insurance agreement. Keep in mind that an insurance company can deny coverage whenever the claim is not part of the agreement.

To learn if there was a breach of your insurance agreement, you may speak with a local attorney about your case. To contact a health insurance expert, you may reach the Stop Health Insurance Denials at 310-695-5241. We are ready to review your case and provide the next steps to challenging the coverage denial in a courtroom.