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

Asked 11 months ago - 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. Pamela Koslyn

    Contributor Level 20

    2

    Lawyers agree

    Answered . 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... more
  2. Michael Charles Doland

    Contributor Level 20

    2

    Lawyers agree

    Answered . 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... more
  3. Tatiana Kadetskaya

    Contributor Level 19

    2

    Lawyers agree

    Answered . 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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