What is my recourse if my health insurer is denying a claim?
Question Details: I had a heart attack about 3 months ago. The closest hospital was not in the network so my insurance company is denying payment. If I had gone on the further 30 miles to an in-network hospital, I would not be here because I was there less than 10 minutes before I coded.
An insurance policy, including health or medical insurance, is a contract. If you believe that the insurer is violating its obligations under the terms of the policy--that is, not paying a claim when the terms of the policy require them to pay--you can sue them for "breach of contract" to get the amount they should have paid. You can only force them to pay if by the policy's plain terms, they had to; if under the terms of the policy, they would not have to pay this claim, then they don't have to, no matter how unreasonable or unfair that is; that is, you can only enforce via lawsuit your rights and their obligations as set out in the policy.