What do you do when insurance companies don't pay legitimate claims?My mother has been fighting this insurance company for over two years.  She bought a policy for hospitalization and outpatient...

What do you do when insurance companies don't pay legitimate claims?

My mother has been fighting this insurance company for over two years.  She bought a policy for hospitalization and outpatient care four months before she was diagnosed with ovarian cancer.  She had no symptoms when she took out the policy, and in fact, had several typical tests done that are suggested of 60+ year olds--all with A+ results.  She paid her premiums on time, and is in no way attempting to defraud the insurance company.  However, they refuse to pay (stating pre-existing illness).  This seems, to me, to be a breach of contract.  Aren't they stealing from her when they drew up a contract which both parties signed, and now they refuse to uphold...yet they took her money? 

Asked on by amy-lepore

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larrygates's profile pic

larrygates | College Teacher | (Level 1) Educator Emeritus

Posted on

Insurance companies are notorious for delaying or denying claims, particularly for health coverage even if the claim is legitimate. The longer they hold on to the money, the more money they make. I have dealt with these issues when I practiced law, and your story is old news, sadly. My suggestion is to call your State Insurance Commission right away, and explain the situation to them. They may need some documentation for you and have that ready. They usually get very quick responses, unless the company plans to pull out of your state anyway. If that doesn't succeed--and my guess is that it will succeed--then hire an attorney. Don't hire an attorney until you have exhausted the administrative auction. Attorneys provide an invaluable service, but most are very busy, and they are not cheap. A claim with your insurance commission is free.  The link below is for but one commission; but you should be able to find the commission for your state online easily.

herappleness's profile pic

M.P. Ossa | College Teacher | (Level 1) Distinguished Educator

Posted on

A suggestion would be to gather all of the medical documentation which states exactly the time and day in which the final diagnoses was made. Contact the agent who sold you the insurance and discuss this information, always keeping the original documents.

There are two ways of getting help: One is through a lawyer who can directly contact the agency and request a copy of the contract that you both signed, and that way they can demonstrate the breach of contract. Some lawyers will only charge if you get money out of a lawsuit against an insurance company.

The other alternative, which I came to find out about just recently, is that every state has what is called a "department of insurance" or an agency that operates under the same concept of investigating claims and the practices of the insurance company. Search in your state or through law firms within your city to find where that place is and proceed with all your documentation to make things right.

Remember that insurance companies are basically placing bets on our time line when they offer certain benefits assuming that they will not be used or cashed in. They are also private corporations and they can get very greedy. Just check below on the link on that info about the department of insurance, and for lawyers in your area. 

And I truly and sincerely hope this is of some good use for you.

rienzi's profile pic

rienzi | (Level 1) Valedictorian

Posted on

I wouldn't mess around with insurance companies when they don't pay: get a lawyer and sue them -well- follow an attorney's advice. Insurance companies are skilled at being evasive and stalling. Then the statute of limitations runs or a person gets tired of the hassle and then the insurance company wins.

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