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Health Insurance Q & As

Question 6 of 6 in Collecting Claims, Dispute Resolution And Denials
More ways health insurance companies can mess with your claim for benefits
In a prior article we discussed some ways a health insurance company can create difficulties for you in reaching a prompt and fair settlement of your claim. Here are some more ways an insurer can improperly affect your health insurance claims submissions:

  1. Failing within a reasonable period of time to affirm or deny coverage for a claim or to submit a reservation of rights. You have every reason to expect prompt and reasonable handling and explanation of your claim. You should not and need tolerate any unreasonable delay by insurer without an appropriate explanation. You need to pay your medical bills because they are your responsibility. It is your credit that is at stake.

  2. Refusing, failing or unreasonably delaying a settlement offer on the basis that other coverage may be available (except as may be specifically provided in the policy). Except as may be allowed in the policy, an insurer cannot delay payment of a payable claim because coverage under another policy may be available. If a claim is payable, it must be promptly paid. Delaying payment is an unfair claims practice and you should challenge it if it happens to you.

  3. Trying to enforce a full and final release from you when only a partial payment has been made and no compromise settlement has been reached. This is a clear form of intimidation. Here again, this is only possible because the insurer holds all the cards. The insurer has the money. You need the money. If done in an improper manner, this is an unfair claims settlement practice.

  4. Refusing to pay a claim without conducting a reasonable investigation. Sometimes an insurer will handle the claim promptly, but unfairly, by denying it without doing a reasonable investigation to determine liability. Many claimants will accept the decision to deny a claim. But if there is any reason for you to believe that the claim is a payable claim, you should demand further investigation. Sometimes insurers operate on the assumption that claimants will not object to an unreasonable denial – or, that a certain percentage will not object and that is money in the insurer’s pocket. You must be alert and not be afraid to challenge a claim decision and to ask for documentation supporting their decision.

  5. Requiring you, as condition of settling the claim, to produce federal income tax returns (unless court ordered). Such a requirement for a health insurance claim is a red flag that the insurer is engaging in unfair claims settlement practices. The insurer has no need for this information to settle a normal health insurance policy claim.


You have one advantage when negotiating with an insurer about a claim when the dispute relates to the application and meaning of policy wording. Because you had no opportunity to negotiate with the insurer about the wording of the policy (the insurer drafted the policy wording), the law will construe (interpret) any ambiguities (lack of clarity) in the wording against the insurer and in your favor. If the policy wording is unclear (or, better yet, favors you), a court of law will most likely rule in your favor.

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