Policy Exclusion Denial

UPDATED: Oct 1, 2022

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Policy Exclusion Denial

I live in TX a mandate fertility state, my insurance is
through BCBS TN. My policy states under exclusion
fertility is not covered in the absence of a disease I
have PCOS auto immune disease that effects
fertility. I was also told on the phone by customer
service it would be covered and have a reference
number and documentation. Now that Ive started
process theyve denied my predetermination based
on policy exclusion, which my doctor is even
shocked based on medical records and the
documents we received and I have no actual
booklet or EOB to verify. Could I sue them for
distress and unjustified denial ?

Asked on November 28, 2018 under Insurance Law, Texas


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 4 years ago | Contributor

If you believe you should be covered but have not been,you could sue for the coverage (e.g. the amounts the insurer should have paid under the terms of the policy). But all you can get is the coverage/payments the insurer should have made, not emotional distress or anything like that. An insurance policy, including health insurance, is a contract; the law does not provide compensation for emotional distress in contract claims.

IMPORTANT NOTICE: The Answer(s) provided above are for general information only. The attorney providing the answer was not serving as the attorney for the person submitting the question or in any attorney-client relationship with such person. Laws may vary from state to state, and sometimes change. Tiny variations in the facts, or a fact not set forth in a question, often can change a legal outcome or an attorney's conclusion. Although AttorneyPages.com has verified the attorney was admitted to practice law in at least one jurisdiction, he or she may not be authorized to practice law in the jurisdiction referred to in the question, nor is he or she necessarily experienced in the area of the law involved. Unlike the information in the Answer(s) above, upon which you should NOT rely, for personal advice you can rely upon we suggest you retain an attorney to represent you.

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