Litigation is often the result of the failure of two parties to reach a mutually acceptable agreement. Insurance companies are the subject of much litigation due to the nature of the services offered. When consumers believe premiums were paid for resources that were not delivered, many resort to lawsuits. Policyholders can sue health insurance companies once a few tasks are performed.
Instructions
1. Determine the state laws regarding liability and health insurance. Each state has a department of insurance. This agency's job is to regulate insurance companies and ensure operations with sound legal processes. Some states will have a division within the agency dedicated to the needs of health insurers and beneficiaries. Others will have guidelines that apply generally to all insurance entities.
2. Follow appeals guidelines for the health insurance company. This is particularly important with health insurers as beneficiaries with chronic conditions often make several trips to various healthcare providers for their care. Timelines for appeals processes are often connected to each procedure/health provider visit. If a beneficiary fails to follow written procedures related to appeals and/or complaints, health insurance companies have precedence to prove noncompliance by the beneficiary.
3. Understand the coverage guidelines of the insurance company. Coverage for an emergency room visit, for example, often only applies to specific life-threatening conditions outlined by the insurance company. The beneficiary may feel gallbladder pain warranted an emergency room visit, while the insurance may state in its guidelines that it doesn't. Terms such as "elective surgery" and "totally disabled" should be clearly understood by the beneficiary before electing to sue an insurance company for failure to cover a specific procedure.
4. Consider arbitration. It is important to weigh the costs of suing an insurance company against the immediate needs of the consumer. Don't let emotions win over common sense. Make sure that a violation has occurred and, if so, that it warrants the time and effort the consumer will dedicate to a lawsuit. Arbitration is a good tool to maintain a working relationship between two parties after a breakdown in communication.
5. Document every step of the process. Health insurance claims often lead to litigation. It is a rule of thumb for any beneficiary to file all documentation received from the health insurance company and any healthcare providers. Write the first and last name of every employee at an insurance company when a conversation occurs and the date and times of each conversation, as well as the resolution of the conversation. Being proactive will mean a shorter trial if and when a suit occurs.
6. Contact an attorney. After the beneficiary has done all the legwork possible in preparation of a suit, an attorney will be able to take the reins and lead the beneficiary/consumer down the most efficient path to resolving any health-claim dispute. Keep in mind that a prudent attorney may advise against a suit. Follow the advice of a trusted attorney.
