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Your health insurance company just denied coverage for medical treatment you desperately need. You’ve paid every premium on time. You followed every rule they gave you. Now you’re staring at medical bills you can’t afford and a rejection letter that makes absolutely no sense. It’s infuriating, and it might be illegal. California law actually protects policyholders from unfair insurance practices, and you may have solid grounds to sue your health insurer. Whether you can win depends on the specifics of your situation, but understanding your rights is the first step.
Understanding Your Policy And The Denial
Start by figuring out exactly why your claim was denied. Insurance companies must provide written explanations for coverage denials. That’s not a courtesy, it’s required. Common reasons include:
- Treatment deemed not medically necessary
- Services classified as experimental or investigational
- Provider considered out of network
- Pre-authorization requirements not met
- Policy exclusions or limitations
Dig into your policy documents. Yes, they’re boring and dense, but they matter. Insurance contracts are binding agreements. If the denial contradicts what your policy actually says, you’ve got ammunition.
When A Denial Becomes Bad Faith
Here’s something important to understand. Not every denial gives you the right to sue. Insurance companies can legitimately deny claims that fall outside policy coverage. That’s frustrating, but it’s legal. What they can’t do is act in bad faith. Bad faith happens when an insurer unreasonably denies, delays, or underpays a valid claim. California Insurance Code Section 790.03 specifically prohibits unfair claims practices. A Berkeley Health Insurance Claim Denial Lawyer can evaluate whether your situation crosses that line. Watch for these red flags:
- Failing to investigate your claim properly
- Denying coverage without a reasonable justification
- Misrepresenting policy language
- Ignoring evidence supporting your claim
- Unreasonably delaying claim processing
Any of these could indicate bad faith. And bad faith opens the door to significant legal remedies.
Steps To Take Before Filing A Lawsuit
You can’t just march into court the day after receiving a denial. California requires you to exhaust internal appeals first, giving the insurance company a chance to reconsider. Request your complete claim file. You’re legally entitled to see every document the insurer used in making its decision. This often reveals exactly where their reasoning falls apart.
File an internal appeal with supporting documentation from your healthcare providers. Medical records matter. Treatment notes matter. Physician statements explaining why the denied care was necessary can completely change the outcome. If the internal appeal fails, you can request an external review through the California Department of Managed Health Care or the Department of Insurance. An independent medical reviewer will evaluate your case without any connection to your insurer.
Legal Options For Denied Claims
Once you’ve exhausted administrative remedies, litigation becomes an option. California allows several legal theories for insurance disputes. Breach of contract claims focus on whether the insurer violated your policy’s terms. If your policy clearly covers the denied treatment, that’s a breach. Pretty straightforward. Bad faith claims go much further. They address how the insurer handled your claim, not just whether coverage technically existed. Successful bad faith lawsuits can result in compensatory damages for financial losses and emotional distress. Sometimes punitive damages too. Timing matters here. You generally have four years from the date of breach to file a contract claim. Bad faith claims have different deadlines depending on the circumstances, and working with A Berkeley Health Insurance Claim Denial Lawyer ensures that your case won’t go to waste because of missed deadlines.
Getting Professional Legal Help
Insurance companies employ entire teams of lawyers to protect their interests. You should have representation too. The Law Office of Bennett M. Cohen understands how California insurance law works and how insurers actually operate behind the scenes. We can review your policy, assess whether the denial holds water, and guide you through appeals or litigation if necessary. Don’t let an unfair denial stand without a fight. Your health matters. Your financial security matters. If you believe your insurance company wrongfully denied coverage, contact us today.
