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Home > FAQ > What to Do if My Health Insurance Claim is Denied or the Insurance Company is Acting in Bad Faith?

What to Do if My Health Insurance Claim is Denied or the Insurance Company is Acting in Bad Faith?

If you have a valid claim that has been denied, or if you have been the target of bad faith conduct by your insurance company, you need to take appropriate steps to either have your claim resolved or build a case for an eventual lawsuit.  Review the denial letter and your policy, gather all relevant evidence, file appeals, and then consider filing a lawsuit if the matter is unresolved.  At all stages, it is highly recommended to have a skilled California insurance lawyer on your side.

Review Your Policy and the Denial Letter

Before you take any other steps, it is important to conduct a thorough review of your policy.  Make sure that your claim is covered by your policy and that it does not fall under any exclusions.  If you can, identify instances in which your insurer has breached the contract.  Compare the justifications made in your denial letter to the language in your policy.  If they use code numbers to explain their decision, check their website for a key, and even call the company for a clear explanation of the denial.  Your insurer is required to clearly explain why your claim was denied, and a vague denial letter (or no letter at all) may be grounds for a claim of bad faith.

Document Everything

From the time you file your initial claim, you should be keeping copies of all documents related to your claim.  Medical records, medical bills, police reports, claim denials, and other documents should all be kept, as well as all correspondence with your insurance company.  Take notes on any calls with insurance agents and other representatives.

Seek Internal Review

Your claim may have been erroneously denied because of an error or misunderstanding on the part of the insurance company.  File an internal appeal, requesting that the insurance company reexamine your claim.  Your insurance company likely has standard appeals forms to fill out.  Even if you use these, make sure to include all relevant evidence and to explain clearly your reasons why your claim should not have been denied.

File a Lawsuit

If your insurance company fails to comply with your demands, refuses to offer a reasonable settlement, or otherwise continues to engage in bad faith conduct, it is time to consider a lawsuit.  You can file a lawsuit based on breach of contract (failing to pay out on a valid claim), based on bad faith conduct (when the company breaches its duty to treat insured people in a fair and reasonable matter), or both.  In a bad faith claim, the company may be liable for fraud or intentional infliction of emotional distress, or even for punitive damages, on top of the value of your claim.

Get a Lawyer

Your first step after a valid insurance claim is denied should be to consult with a knowledgeable insurance lawyer.  Insurance is a complicated arena, and fighting with an insurance company is a difficult and labor-intensive process.  Let someone who has been there hundreds of times shoulder the burden for you.

Fight Back Against Wrongful Claim Denials and Bad Faith Conduct With Help From Gianelli & Morris.

If you are a California policyholder or beneficiary and you have been subjected to bad faith conduct by an insurance company, or if your valid insurance claims have been denied by an insurance company in California, call the insurance law attorneys Gianelli & Morris for a free consultation regarding your case.

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