Healthcare bills can be a serious financial burden. And if you’ve had a difficult experience dealing with your health insurer, you might be wondering what legal recourse you have. Filing a lawsuit against your health insurance company is an option—but should it be?
The answer to this question depends on many factors, so getting informed legal advice from an experienced attorney is the best way to make sure you understand your rights—and what might be possible in the case of a lawsuit. In this article, we’ll break down the basics of using a health insurance company, but keep in mind that the information provided here is no substitute for professional advice. With that said, let’s get started.
What Makes a Lawyer Qualified to Sue Health Insurance Companies?
When it comes to suing health insurance companies, you’ll need the right type of lawyer – a qualified attorney who specializes in insurance disputes. These experts understand the complexities of a health insurance policy and are able to provide legal advice and representation on how to resolve an issue.
But what makes a lawyer qualified to sue health insurance companies? When considering an attorney, they must be able to show that the health insurance adjuster or company owed the patient a duty to act in a certain way. This is usually linked to a contractual agreement between the insurer and its customers. Attorneys must be familiar with this specific area of law and have experience representing clients in court against health insurers.
Since suing an insurance company is complicated, it’s recommended to hire a lawyer or law firm with the qualifications and experience necessary for success. A qualified attorney can help protect your rights, ensure that you receive fair compensation, and pursue any other legal remedies available.
How Much Does It Cost to Hire a Lawyer to Sue a Health Insurer?
When it comes to suing a health insurance company, the cost of doing so will depend on the lawyer you choose and the type of case you’re filing. Generally, a lawyer’s fees will range from $100 to $400 per hour. Plus, you may also need to pay court filing fees for a motion in your lawsuit; usually, this fee is about $20 per filing.
As for settlements or awards that come out of your case against the health insurer, most personal injury lawyers take 33% off the top as their fee. That said, some lawyers may charge more or less depending on the complexity and duration of your case.
Ultimately, it’s important to consider your lawyer’s past experience when it comes to suing health insurers and how much time he or she expects it to take. By doing some research upfront, you can make an educated decision about who you’d like to work with and what kind of retainer agreement makes sense for both parties.
How to Select the Right Lawyer for Your Case
Now that you know a few different ways to get referrals for lawyers, let’s talk about how to actually pick the right lawyer for your case. Since attorneys often specialize in a few different types of cases, it’s best to start by making sure the lawyer you’re considering is experienced in cases similar to yours.
You can do this by researching them online, reading their reviews from past clients, and checking out any professional organizations they may be part of. If they have any special certifications or awards related to your type of case, that’s a plus too.
Once you’ve done some research and have your shortlist of attorneys ready, here are some things you should ask when evaluating:
- How many cases have you taken on like mine and what was the outcome?
- How do you plan to approach my case?
- What is your estimated timeline for final resolution?
- Will I be consulted before any payments are made?
- Have you worked with my health insurance company before?
- What other support services might I need?
What Kind of Evidence Is Necessary to Win a Case Against a Health Insurer?
Assuming you can prove that your health insurance company didn’t conduct a full and fair review of their decision or that they denied or reduced medically necessary services, you will need a lawyer to help you put together the pieces of the case.
So, what kind of evidence is necessary to win a case against a health insurer? Here are some of the common elements:
Medical records
You’ll need to prove that your treatment was medically recommended and necessary for your specific condition. Your medical records are key — they must show the diagnosis, treatments and services rendered by healthcare providers as proof.
Explanations of benefits (EOB)
These documents show what treatments have been approved and/or rejected by the health plan, along with reasons why they came to their decisions. In addition, you may also need medical policy files from the insurer to compare against your medical records.
Provider agreements
These can include contracts between the health plan and its network providers, which describe how their services are reimbursed.
Certain evidence can determine if an insurance company made mistakes in their decision-making process. Having a lawyer experienced in dealing with health insurers is an invaluable asset during this process — so don’t hesitate to call one for help!
How to Find a Lawyer to Represent You
When it comes to finding a lawyer to represent you in a suit against a health insurer, you have plenty of options. Here are the best ways to find the right lawyer for your case:
- Tap your network: Ask trusted friends and family, as well as business associates, if they have any referrals. Word-of-mouth is one of the best sources of information when it comes to finding an attorney because they’ve already seen how they operate and can vouch for their expertise.
- Look for lawyer directories: There are plenty of websites that offer comprehensive profiles on attorneys across various practice areas—allowing you to get specific information on lawyers who specialize in suing health insurers.
- Get referrals from bar associations: Most local bar associations provide lawyer referral services and are a great resource when searching for an experienced attorney who has expertise in suing heath insurers.
Case Study: How One Attorney Took on a Health Insurer and Won
Now let’s take a look at a real-life case study of how one attorney took on a health insurance company. In 2017, New York Attorney General Eric Schneiderman sued UnitedHealthcare over its failure to provide mental health and substance abuse benefits to 20,000 New Yorkers. After a lengthy legal battle, UnitedHealthcare agreed to pay $13.6 million in restitution as well as change its policies — in hopes of reforming its practices to comply with state regulations.
This is just one example of an attorney successfully suing a health insurer in order to protect the rights of their clients. But it isn’t just individuals that get the benefit of suing health insurers; in 2019 a Florida medical practice was accused of exploiting Medicare Advantage by submitting $2.3 billion in improper claims and was hit with a lawsuit for Medicare fraud.
Lawsuits aren’t limited to instances of accused fraud or abuse though — some lawsuits can challenge the very policies and services offered by health insurers. For example, many states allow individuals to sue their insurance companies over policies that affect free preventive checkups for those who pay for health insurance coverage. In these cases, individuals want corporations held accountable for denying those benefits that should be provided as part of an agreement with the insurance company.
Strategic Considerations for Filing Suit Against a Health Insurer
Before deciding to sue a health insurer, there are a few strategic considerations that you should take into account. First, consider whether the insurance company is using mandatory arbitration to escape accountability for denying coverage. Many health insurers require customers to waive their right to sue in court and resort to arbitration instead; however, be aware that this process can be costly and time consuming.
Second, think about any monopsony concerns that might arise from health insurer mergers. Monopsony power occurs when a larger entity exerts control over the supplier market—in this case, when a large health insurer has too much influence over the market for healthcare services and products.
Finally—and perhaps most crucially— consider whether the insurance company is failing its customer in bad faith. This can include denying claims without reasonable justification or not providing sufficient information on why a claim was denied. If any of these conditions exist in your situation, then it’s important to consult with an attorney who can help you make the case that you should be receiving what you were promised in your coverage agreement.
Conclusion
Taking legal action against a health insurer can be a difficult, but ultimately essential step. The best way to pursue your case is to find a lawyer who understands the nuances of the law and can help you through the process.
It’s important to remember that even if you are successful in your case, the law is far from perfect. Unfortunately, the situation in which you find yourself is just one of the many ways in which health insurers have been attempting to deny people access to the care they deserve. The ultimate goal is an equitable system that works for all.
By taking the steps to hold health insurers accountable for their actions, you are helping to push that goal forward. Knowing your legal rights is an important part of being an engaged and empowered patient—it could just be the difference between getting the care you need and getting denied.