What can I do if my insurance company is denying my medical claim?

Insurance Claim Denied: Elements of Insurance Bad Faith

To succeed in an insurance bad faith claim, you need to prove:

There is a mutual binding insurance coverage contract between the plaintiff and defendant

The insurer refuses to pay benefits under the contract

The insurer’s bad faith or unreasonable action is a breach of the implied covenant of good faith and fair dealing in the contract

That bad faith or unreasonable action caused damage to you (the insured)

South Carolina law does state that an insurer cannot be held in bad faith for a refusal to pay out on an insurance policy if there is a reasonable basis for objecting to or denying the insured’s claim.

If an insurance company denies a claim, the question of whether an objectively reasonable basis for the denial existed will depend on the particular circumstances of the incident on which the denied claim was issued.

What Is a Bad Faith Action?

South Carolina Code Annotated Section 38-59-20 defines the actions that constitute bad faith by an insurer offering property and casualty, marine, surety, or title insurance. These actions can constitute improper claims practices:

Failure to acknowledge, with reasonable promptness, critical communications regarding any claims that arise under its policy, which includes third-party claims under liability policies

Knowingly misrepresenting to either the insured or third-party claimants any pertinent facts or policy provisions that relate to coverage issues or disseminating misleading or deceptive information regarding the coverage under the policy

Not adopting or implementing reasonable standards for promptly investigating and settling claims, which includes third-party liability claims

Offering to settle a claim, which can include a third-party liability claim, for less than what is reasonably due or payable based on a chance that the policyholder or claimant would be required to incur attorney fees to recover the amount reasonably payable or due

Compelling a policyholder or third-party claimant under a liability policy to initiate a lawsuit to recover money that is due or payable with respect to claims under its policies by offering an amount that is substantially less than what is ultimately recoverable through a lawsuit or settlement with an attorney

Threatening to invoke or invoking a policy defense, or rescinding the policy as of its inception, in bad faith, for the primary purpose of reducing or discouraging a claim, including third-party liability claims

Similar actions may also be considered bad faith for other types of insurance claims denied according to other types of insurance policies.

How to Protect Yourself Against Insurance Company Tactics

While insurers want to pay you as little as possible for your damages, there are actions you can take to protect your rights. Our South Carolina denied insurance claim lawyers recommend that you:

Read your insurance policy carefully. You should know precisely what is covered and how to appeal if the insurance company denies your claim.
Be careful about filling out forms. Even if you make an honest mistake, your insurance provider may seize that as a reason to deny your coverage retroactively.
Do not cash a premium refund check without contacting your insurance claims attorney. If your insurance company rescinds your insurance, they may send you a refund for the premiums you paid. Cashing it may be interpreted as accepting their decision.
Put everything in writing. Calling your insurance company is likely to be a frustrating experience, and you will not be able to prove anything that a company representative tells you over the phone. Keep records of all correspondence.
Contact your state insurance department. They may be able to help you, but they will not represent you in a private matter. For that, you will need a South Carolina denied insurance claim attorney.

Most of all, do not give up. Insurance companies count on you to give up. Fight for your rights.

Unfair Insurance Denials Can Have Life and Death Consequences

Imagine you receive the devastating news that you have cancer. It is operable, and you have a chance to survive with prompt care. You make it through the surgery and begin chemotherapy treatments. Then, the insurance company suddenly cancels your insurance retroactively. The reason? They allege that you lied about your weight on the insurance application. Now, you are left with hundreds of thousands of dollars in medical bills, unable to afford the rest of your chemotherapy schedule, and facing an uncertain prognosis.

This is the situation Patsy Bates, a 51-year-old hair stylist, found herself in after her health insurance was "rescinded." Bates health insurance company, Health Net, Inc., rescinded her policy in the middle of her treatment for breast cancer, saying she provided inaccurate information in her insurance application.

Health insurers such as Health Net and Anthem Blue Cross of California have been accused of illegally retroactively canceling or rescinding the policies of people whose conditions are expensive to treat. The cancellation usually happens when people are in the middle of their treatment.

Los Angeles City attorneys sued Anthem Blue Cross to try to stop the company from rescinding insurance policies. The city's attorneys claimed that "[t]he insurance company has engaged in an egregious scheme not only to delay or deny the payment of thousands of legitimate medical claims but also to jeopardize the health of more than 6,000 customers by retroactively canceling their health insurance when they needed it most."

Bates already had health insurance when an agent from Health Net walked into her hair salon, promising he could lower her monthly premiums if she bought a policy with Health Net. The agent asked questions from the application while Bates worked on her client's hair. She answered the questions as best she could, and her application was approved.

Not long after, Bates was diagnosed with breast cancer and began aggressive treatment that included surgery to remove the tumor and months of chemotherapy. The night before her surgery, a hospital administrator walked into her room and told her that the hospital could not allow her surgery to proceed because Health Net did not authorize it. The company would only authorize the procedure if she immediately paid the next three months of premiums.

Following the surgery, Bates began chemotherapy treatment. Not long after, Bates was notified that Health Net was canceling her insurance policy, saying she lied about her weight on her application and did not disclose that she had been screened for a heart condition in the past. The rescission left Bates saddled with medical bills and forced her to suspend chemotherapy for months until she found a charity to pay for it.

Documents disclosed at Bates' arbitration hearing revealed that Health Net rewarded employees who rescinded sick patients. The company paid bonuses to employees who met cancellation goals and even commended one employee for having a "banner year" when she allowed the company to avoid "$6 million in unnecessary health expenses."

Retired Los Angeles Superior Court Judge Sam Cianchetti, who arbitrated Bates' case, called Health Net's behavior "egregious," saying the company "was primarily concerned with and considered its own financial interests and gave little, if any, consideration and concern for the interests of the insured."

Cases like these happen all over the country when an insurance company attempts to deny a client based on their expensive treatment. When a client has paid their premiums and then is denied coverage or dropped from their policy, there may be an act of insurance bad faith. South Carolina denied insurance claim attorneys like those at Derrick Law Firm Injury Lawyers deal with insurance companies daily. We understand the policies written and the laws these companies must abide by, and we will fight for your fair treatment after the insurance company's decision.

Have You Been Denied an Insurance Claim? Is Insurance Delaying Your Payment?

If you've been denied an insurance claim or the insurance company is delaying your payment, you should speak with an experienced insurance claim attorney as soon as possible. Please contact us online or call our Conway office directly at 843.248.7486 to schedule your consultation. We are also able to meet clients at our Charleston, Myrtle Beach, Murrells Inlet, Mt. Pleasant, North Myrtle Beach, Florence, or North Charleston office locations.

We are Proud To Serve Personal Injury Clients Throughout South Carolina

With seven office locations in Myrtle Beach, North Myrtle Beach, Conway, Mt. Pleasant, North Charleston, Murrells Inlet and Charleston and over 30 years of experience with personal injury cases. Derrick Law Firm Injury Lawyers has the knowledge, skill and experience to protect you and your family.

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