Suing Our Insurance Company

[Anonymous]

Has anyone had any luck suing their insurance company for coverage of OT services? Our insurance company is denying our claims that are clearly covered within our policy, and we are getting ready to file a lawsuit. We are looking for an excellent and reasonably-priced lawyer to represent us. Any recommendations would be greatly appreciated! Thanks.

[Anonymous]

i'm no expert, but if you get insurance thru an employer, then you cannot sue your insurance company -- you have to sue your employer, under ERISA. it is very hard to sue insurance companies -- congress has protected them very well.

[Anonymous]

Have you gone through the apeals process with the insurance company.

[Anonymous]

If your insurance company is through your employer and ERISA applies (it does not if you are government or church or if your employer does not have enough employees for ERISA to apply), you first have to avail yourself of all of the appeals processes afforded under the policy. There is a rather short deadline for doing so and if you miss the deadline, you will most likely be barred from suing.

If you are going to sue, your suit would be against the insurer if your health plan is funded by a policy of insurance. If your employer self insures and the "insurer" is merely acting as a third party administrator, then the suit would be against the employer.


I have not personally sued my own insurer. But, for many years, I represented people who did and was highly successful when coverage actually existed according to the plain language of the policy and the insured had not missed any appeal deadlines.

I don't presently know anyone who represents individuals who are suing their insurer. However, when you look for an attorney, make sure you find one that knows about ERISA if it applies, otherwise you will be paying a lot of fees for the attorney to get up to speed on the law. If ERISA does not apply, then any contract attorney can help you. I can tell you that only a handful of practitioners actually to this type of work.

[Anonymous]

Anonymous wrote:Has anyone had any luck suing their insurance company for coverage of OT services? Our insurance company is denying our claims that are clearly covered within our policy, and we are getting ready to file a lawsuit. We are looking for an excellent and reasonably-priced lawyer to represent us. Any recommendations would be greatly appreciated! Thanks.

We've looked into it, and as pp's shared, it's very difficult. We are leaning toward 2 options now: 1) Getting in touch w/ someone (lobbyist?) who can get Obama to recognize the special coverage needs of kids w/special needs & put something in place & 2) getting some good media exposure that will get the former to recognize this.

If you (or anyone else) has any ideas of how to get something like this started, count us in. For us, having definitive, comprehensive coverage for PT, OT, speech therapies for kids being habilitated without parents having to jump through hoops to get pre-authorizations, pre-approvals then payouts at only 20-75% would be our family's goal.

[Anonymous]

Our insurance has been good about coverage. I definitely recommend the appeal process first. We have done that for other serrvices and it worked. Documment everything-all coversations with them, keep every item they mail. Find out if you can appeal again. Go through every possible avenue they let you use before getting a lawyer.

[Anonymous]

Anonymous wrote:Our insurance has been good about coverage. I definitely recommend the appeal process first. We have done that for other serrvices and it worked. Documment everything-all coversations with them, keep every item they mail. Find out if you can appeal again. Go through every possible avenue they let you use before getting a lawyer.

Not OP, but what can you appeal? Our issue is huge co-payments and no therapist is considered 'in network'. Then again, most pediatrica therapists in our area do not accept insurance.