Has anyone succeeded in suing health insurance companies?

Yes! Over time, many consumers have taken legal action against a good number of the nation’s largest and best known health insurance companies. Some of these actions have been successful; many have not. Many others are tied up in the U.S. court system at one level or another, waiting their turn to be heard.

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Lawsuits are filed each day in every city and state in the union. As our society has become more litigious, more and more citizens have to chosen to pursue their legal rights in situations where they have been denied medical benefits or their insurance company has chosen to cancel or withdraw coverage after the fact.

Was it always like this?

A generation ago, filing a malpractice suit against a doctor or other medical service provider was a rare occurrence. Filing suit against a giant insurance company was even more unusual. Health insurance was also different in those days, generally being limited to major medical and hospitalization coverage.

The economic climate of the mid twentieth century was also quite different than it is today. By comparison, our country was in robust financial health with the average family able to pay for its needed services and still save for a rainy day. The standard of living for Americans continued to increase until the early 1970s.

What’s different today?

Much has changed in the past 50 or 60 years, and the average American family can no longer afford the costs of medical care and treatment without some form of meaningful insurance protection.

As medical costs have increased, so have the costs of insurance! Insurance companies have shown tremendous profits in recent years, making dramatically higher health insurance premiums that much harder for consumers to swallow. Rather than pay up, many health providers choose to cancel the policies of consumers with unusually large, (and in many cases legitimate) claims.

This has been good for the insurer’s bottom line but leaves consumers broke and despondent They are not only still looking for solutions to their medical problems, but are now buried in debt by medical services already provided, but whose health insurance claims have been denied.

How do insurance companies get away with this?

As with many types of contracts, health insuranceagreements contain a lot of fine print, providing many legal loopholes for companies looking to weasel their way out of paying a policyholder’s claims. One of the most arguable clauses in virtually every health insurance contract has consistently been the pre-existing conditions clause.

The process of filing a lawsuit is usually both expensive and complex. Consumers are often reluctant to wage legal war against insurance companies with deep pockets and prestigious law firms at their disposal. However, recent changes in health care legislation have put laws on the books to aid consumers in filing claims and appeals against health insurers.

How has the Affordable Care Act of 2010 changed the legal process?

A major portion of the Affordable Care Act dealt with increased consumer rights and protections. The Act created a patient’s bill of rights, designed to help consumers make better health care decisions.

Each state must sponsor an assistance program to help consumers with legal matters. These programs will help consumers file complaints or initiate legal action against insurance companies.

The Act also extended consumers’ appellate rights under the law, allowing more time for the appeal process and guaranteeing a consumer’s right to appeal directly to the insurance carrier. This process is known as an internal review.

If a consumer’s appeal is turned down, the new law provides for a second, “external review.” This is a review by an independent third party organization, which may decide to overturn or could choose to uphold the insurance company’s original decision.

Another important outcome of the Affordable Care Act is to no longer permit a limitation or denial of benefits to any child under the age of 19 with a pre-existing health condition. In 2014, the protections for pre-existing conditions will extend to all Americans, regardless of age.

What if I have been denied coverage?

There are now more insurance choices for those needing insurance or who have been denied coverage for one reason or another. The 2010 Act created a pre-existing condition plan (PCIP) for adults.

This provision of the new law guarantees affordable health coverage to all citizens and legal residents who have been denied coverage due to pre-existing conditions, and have been uninsured for a minimum of six months.

In addition to the previously mentioned changes, coverage has been extended for all children covered under a parent’s health policy, to age 26. In some states, Ohio for example, a child’s health insurance coverage can be carried forward until age 28.

In 2014, provisions of the Act allow for the creation of a new type of consumer driven non-profit health insurer, CO-OP program. Insurance shopping will be easier in 2014 through newly formed, state based, affordable insurance exchanges.

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