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Should I take legal action against a major health insurance company?

Cleveland, OH |

I will attempt to convey details as concisely as possible.

I had a deformation in my jaw resulting in evolving sleep apnea and also induced a speech impediment. The severity of the deformation required surgery.

When speaking with my insurance, they denied two appeals seeking coverage of said surgery.

I then engaged in a teleconference with a surgeon of the insurance company, my surgeon, myself, and an insurance representative.

I later received documentation from the insurance company noting that the decision to overturn the denial for coverage had been met.

I had the surgery last year and my insurance paid $72k for the hospital stay however refuse to pay for the procedure itself which was $14k and is soon going to collections.

Any advice would be much appreciated.

Attorney Answers 3


  1. This is obviously a factually complex situation that requires review of all the documentation involved. But I don't think any lawyer would advise anyone to sue a "major health insurance company" for $14,000, especially when that insurer has paid several times that amount for related coverage. You need to see your own litigator to get a more personalized response.

    Avvo doesn't pay us for these responses, and I'm not your lawyer just because I answer this question or respond to any follow-up comments. If you want to hire me, please contact me. Otherwise, please don't expect a further response. We need an actual written agreement to form an attorney-client relationship. I'm only licensed in CA and you shouldn't rely on this answer, since each state has different laws, each situation is fact specific, and it's impossible to evaluate a legal problem without a comprehensive consultation and review of all the facts and documents at issue.


  2. The first place I would look would be the insurance policy terms for appealing an adverse decision. Pay special attention to time deadlines.

    I think that suing to recover $14 where the company paid $72 will be an uphill battle, and trying to do so without an attorney - - even more so.

    The above is general legal and business analysis. It is not "legal advice" but analysis, and different lawyers may analyse this matter differently, especially if there are additional facts not reflected in the question. I am not your attorney until retained by a written retainer agreement signed by both of us. I am only licensed in California. See also avvo.com terms and conditions item 9, incorporated as if it was reprinted here.


  3. Check to see what your insurance policy says about denial of benefits. Your attorney may file a demand before you proceed to litigation.

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