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Can I sue Health Insurance company to accept liability to pay medical bills ?

Houston, TX |

I purchase health insurance plan for my parents. As per plan we paid 20% of all bills and then after reviewing all paperwork insurance should pay remaining 80% to the provider. Few weeks after the appointment insurance declined to pay the bills saying that "its pre-existing case". However my parents never been treated with those diagnostics. Insurance even declined the bill for office visit to arrange Family Doctor.
Now I'm getting tons of mail from the providers requiring to pay full amount.
Please advise

Attorney Answers 4


  1. I am an attorney licensed in the Commonwealth of Pennsylvania, and the States of Delaware and New Jersey. My practice includes employment, business and health care law. Before I respond to your inquiry, I must state that we have not spoken, I have not reviewed the relevant documents and facts, and I do not represent you. Therefore, my discussion below is not a legal opinion, but is informational only. Finally, my discussion applies only to issues to which Pennsylvania, Delaware, New Jersey or Federal law applies.

    That being said, claims like the one you describe are complex; you can sue if the denial of benefits was wrong or violated the law. You will have to go over this in great detail with a health law or insurance benefits attorney in your area.

    /Christopher E. Ezold/

    I am an attorney licensed in the Commonwealth of Pennsylvania, and the States of Delaware and New Jersey. My practice includes employment, business and health care law. Before I respond to your inquiry, I must state that we have not spoken, I have not reviewed the relevant documents and facts, and I do not represent you. Therefore, my discussion below is not a legal opinion, but is informational only. Finally, my discussion applies only to issues to which Pennsylvania, Delaware, New Jersey or Federal law applies.


  2. You need an attorney who is experienced in insurance coverage and bad faith law. Research on AVVO, or consult with your local bar association. Health insurers will find many reasons to deny claims, and sometimes you will need to appeal, and then re-appeal before starting an action to force them to pay. Maintain good contact with your parents' health care providers and keep them advised of your attempts to get their insurer to pay the bills. These claims are time sensitive, so don't delay finding an attorney in your area to help you.


  3. Find an attorney in your area who handles insurance disputes with health insurance companies. Quite often, they will try to deny any claims they possibly can. You may have one of the grandfathered plans that was intact prior to the implementation of the ACA. New plans must cover pre-existing conditions. Nevertheless, just because the pre-existing condition exclusion applies, someone still needs to evaluate the records to determine whether that actually is the case, or whether the insurance company is just trying to keep its profits.
    Best of luck to you!
    Tara Candela, RN, BSN, JD


  4. Check first with the providers first to see whether they have appealed the claim denial. Sometimes bills come in while the appeals are pending. If they have not appealed it, or if the appeal was denied, consider hiring an attorney familiar with health insurance laws to contact the insurer to demand payment. Gather together the explanation of benefits forms and the benefit booklet for the healthcare plan so that the lawyer can review them. Dealing with health insurers can be very frustrating. Best of luck to you!

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