Can you sue a health insurance company for denying coverage?
Asked by: Prof. Bessie Osinski | Last update: October 23, 2025Score: 4.4/5 (65 votes)
Can you sue health insurance for denying coverage?
There are laws designed to protect consumers in the state of California and across the nation. It's not uncommon for policyholders to sue their healthcare insurers for denial of a claim, mainly when the claim is for a service that is crucial to their health and future or the health and future of a loved one.
When should you sue an insurance company?
You may be able to sue your insurance company for bad faith if they intentionally neglect to perform the duties necessary according to your policy. If the insurance company knows that the claim is valid but they deny it anyway, you may be able to sue for bad faith.
Is it illegal for insurance companies to deny coverage?
Yes, there are several reasons why a car insurance company can deny coverage, but if you are turned down by one company, you may still have options for coverage. Every carrier has its own rules about who it will cover, so if one company denies you coverage, you may still have options.
What to do if the insurance company doesn't want to pay?
If your health insurer refuses to pay a claim or ends your coverage, you have the right to appeal the company's decision and have it reviewed by a third party. You can ask that your insurance company reconsider its decision. Insurers have to tell you why they've denied your claim or ended your coverage.
Health Insurance Denials
Which health insurance company denies the most claims?
According to the analysis, AvMed and UnitedHealthcare tied for the highest denial rate, with both companies denying about a third of in-network claims for plans sold on the Marketplace in 2023, respectively.
How do I force an insurance company to pay?
Keep in mind that insurance companies are never forced to pay any injury claim until you have a Court Order called a “Final Judgment” telling them they must pay you. Until you have that in your hand, they only pay if and when they want to. Filing suit is how you take control of your case.
Why would a health insurance company deny coverage?
Perhaps the most common reason a health insurer may deny your application is because you have one or more pre-existing medical conditions. A pre-existing condition is any health condition, diagnosed or undiagnosed, you have at the time of applying for an insurance policy.
What does the Affordable Care Act do?
Under the Affordable Care Act, patients who may have been uninsured due to preexisting conditions or limited finances can secure affordable health plans through the health insurance marketplace in their state.
Can a company deny health insurance?
Employers must offer health insurance that is affordable and provides minimum value to 95% of their full-time employees and their children up to the end of the month in which they turn age 26, or be subject to penalties. This is known as the employer mandate.
How likely is an insurance company to sue you?
While subrogation allows insurance providers to pursue third parties, an insurer usually cannot sue their policyholders. However, there are certain situations where an insurer may take legal action against its policyholder.
What is an example of negligence in insurance?
Negligence is an insurance term that is tied to various types of liability insurance, such as home, life, health, business, and auto. For example, perhaps a retail shop owner was negligent by leaving their water hose out after cleaning the sidewalk, causing a passerby to trip.
Do you have to have a lawyer to sue an insurance company?
If you've found yourself in this situation and are considering legal action, you might be wondering if you can sue an insurance company without hiring a lawyer. It is definitely possible, but it's essential to understand the potential challenges and complexities involved.
Can I sue my insurance company for emotional distress?
Yes, you can sue for emotional distress under the common law standard, but it can be hard to prove. This is because you must show that the result of your claim denial caused you pain and suffering or emotional distress. This intangible loss can be more difficult to prove than, say, the cost of medical bills.
How many insurance claims are denied each year?
A separate KFF survey also found that people with private insurance are more likely to have denied claims than those with public coverage. Overall, 18% of insured adults said they'd experienced a claim denial in the past 12 months, according to the survey.
What to do if an insurance company is stalling?
- Ask the adjuster for a complete list of documents and information needed to fully evaluate your claims.
- Keep physical copies of all evidence that can support your claim.
- Follow up with the insurance company regularly.
Who enforces ACA violations?
CMS, on behalf of the Department of Health and Human Services (HHS), is responsible for enforcing applicable provisions of title XXVII of the Public Health Service Act (PHS Act), including those added by the Affordable Care Act (ACA), the No Surprises Act (NSA) and the Transparency provisions of the Consolidated ...
What are the odds of winning an insurance appeal?
Only half of denied claims are appealed, and of those appeals, half are overturned! Undivided's Head of Health Plan Advocacy, Leslie Lobel, says that if you have a winner argument and patience to get through all the levels of "no," there is a good chance you can get your denial overturned.
What is a dirty claim?
The term dirty claim refers to the “claim submitted with errors or one that requires manual processing to resolve problems or is rejected for payment”.
Why did my health insurance not cover me?
Summary. There are a variety of reasons a health plan might deny a prior authorization request or a medical claim. The service might not be covered by the health plan, or the health plan might require specific procedures to be followed in order to have coverage (a referral from a primary care physician, for example).
What is it called when an insurance company refuses to pay?
If you have submitted a valid claim to your insurance company, and it is refusing to pay or settle your claim, the insurance company may be acting in bad faith.
How do you get an insurance company to pay you directly?
Payout under Property Damage Liability by the Other At-Fault Party: Check in Your Name: In the case of smaller third party property damage claims, IE: If the other party is at-fault and paying for the damage it is not uncommon for the insurance company to pay you directly. Just ask them to issue the check in your name.
How often do insurance appeals work?
The statistic is particularly alarming when one considers that the overwhelming majority of appeals—83.2%—resulted in the insurance company either partially or fully overturning the initial prior authorization denial in 2022. That figure is similar to what the overturn rate was between 2019 and 2021.