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.
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