I need a lawyer that would sue by medical insurance for non payment of an operation. And can I sue for pain and suffering?

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I need a lawyer that would sue by medical insurance for non payment of an operation. And can I sue for pain and suffering?

I had TMJ surgery and my insurance would not cover the operation. I have documentation that it was medically necessary from my doctor. I had the same operation done twice before 10 years ago. I paid out of pocket and need a lawyer to take case and if I can get pain and suffer for the length of time the insurance company **** there feet on my case?

Asked on April 17, 2009 under Insurance Law, Maryland


FreeAdvice Contributing Attorney / FreeAdvice Contributing Attorney

Answered 15 years ago | Contributor

There are several issues you are raising.

First, is the procedure covered by the policy? Not everything that a doctor or dentist claims is medically necessary is covered. Some things are specifically excluded from the policy. Others are excluded as a pre-existing condition. Others are covered under only limited circumstances.

Assuming the operation and related expense is found to be covered by your policy, you are asking am I entitled to anything more than to be paid for the cost of the operation?

That depends on a series of factors, including under some circumstances, if there was bad faith involved. Not all wrongful denials are bad faith.

If the health policy was obtained through a private employer as part of a benefit plan -- even though you contributed to the premium -- under ERISA you could not recover for bad faith damages, period. You could be awarded the cost of attorneys fees however.

If it's a privately purchased plan, or you work for an employer excluded from ERSIA (and any state verision of ERISA) and you were covered and the carrier acted unreasonably then you conceivably could get consequential and punitive damages if there was bad faith.

To find a lawyer visit www.AttorneyPages.com and look under insurance lawyers.


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