Insurance Bad Faith Claims practices are fairly common. A quick internet search will show you that. Bad faith insurance claims practices arise in many different insurance situations with all shapes and sizes of insureds (buyers of insurance), who become victims of the fraud, deceit and greed of their own insurance companies who they may have been paying premiums for many years or even decades for the very thing for which they are now denied coverage. The victims are individuals, small business and even large companies. In short, even a large company or corporation can fall victim to the behemoth insurance companies with whom they do business. If that is true, what chance do you have fighting your insurer over the wrongful denial of your insurance coverage.
Keep reading. You can do more than you think.
Denial of Coverage for Necessary Medical Care
Of all the varieties of bad faith, denial of medical claims is the most disgusting of all. Simply put, hundreds of thousands of people every year are wrongfully denied coverage in the time of their greastes need and vulnerability. Many of thes folks have been payin g espite having paid insurance premiums for decades.
You might think its rare, but it is not. In fact, wrongful denials of coverage are built into medical insurance industry policies, processes and procedures. The insurance industry actually creates computer software designed by the to automatically deny claims. That’s just the beginning of the rigged system that kills countless Americans every year and causes permanent harm and suffering to exponentially more. The so-called “medical director” that signs the letter denying your coverage for medical care in all likelihood either briefly glanced at your medical records or never saw them at all. That explains how one “medical director”, according to Propublica’s article “How Cigna Saves Millions by Having Its Doctors Reject Claims Without Reading Them”, was able to deny 60,000 claims in a month. What is remarkable is that insurance companies deny coverage routinely for care recommended by patients’ doctors who are real practicing doctors not the insurance industry variety who get paid for simply signing denials without ever seeing the patient and in many cases, as with Cigna, without having seen a single medical record or even reviewed the claim form.
If this happens to you or a loved one, don’t lie down and take it as the insurance industry expects you to do. Fight back and fight back hard. After all, your health, if not your life, depend on it.
Recourse for Victims of Insurance Bad Faith
There are many possible claims in New Mexico for bad faith denial of insurance coverage. In fact, New Mexico law is stronger than most states in protecting consumers and specifically consumers of insurance. Here is a short list of possible legal claims:
Tort claims are basically personal injury claims for the harm caused by the bad faith denial of insurance coverage.
Breach of Contract:
Insurance policies are contracts and the insured individual or business has all the rights protected under New Mexico contract law.
Common Law Fraud:
Common law fraud is just plain good ole fashioned fraud, deceit, misrepresentation and so on of which the insurance industry practices in spades. Suffice it to say that there are many ways that claims for fraud can arise in the context of bad faith denial of coverage.
Unfair Trade Practices and Fraud under New Mexico’s Insurance Code:
As mentioned, New Mexico has strong protections for insurance buyers, i.e. the insured person, family and/or business. New Mexico’s Insurance Code is very protective of buyers of insurance.
Unfair Trade Practices.
These claims arise under New Mexico’s consumer protection laws. Again, New Mexico is very protective of consumers, especially consumers of insurance.
Intentional Infliction of Emotional Distress:
This is a common law tort (personal injury claim) in New Mexico. It takes little effort to imagine the emotional distress on a person and family when a medical insurer denies critical life-saving coverage for medical care. The same holds true to varying degrees for all other denials of coverage in an insured’s time of need.
Punitive damages are the real threat to insurance companies that engage in bad faith denial of coverage. Punitive damages can be many multiples of compensatory damages with many 7, 8 and even high 9 figure verdicts around the country for particularly disgusting practices. The adage “if it don’t make money, it don’t make sense” is never more true than for the insurance industry. The industry has calculated that it makes more sense and more money to deny claims because very few consumers will sue. The only way to change that thinking is to wreak havoc on that calculation. That’s what punitive damages do.
First Steps to Protect Your Rights When Your Medical Coverage Has Been Wrongfully Denied
To protect your rights, there are a few things you need to do and a some documents you need to collect right away, even before you call an attorney. Here are the things a lawyer is going to want to see before deciding whether or not the actions of your insurance company merit a lawsuit:
- Medical documents showing that the treatment for which coverage was denied was recommended by your doctor.
- A complete copy of your insurance policy, including any addendums. The insurance company has to provide you with this by law.
- Proof of payment on your policy showing that the policy was in effect at the time of the denial of coverage. The insurance company has to provide you with this by law.A law
- All, correspondence, emails and any other documentation related to the denial of coverage by your insurance company, including the letter of signed by the aforementioned “medical director” denying coverage. The insurance company has to provide you with this by law.
A lawyer is also going to want to see the following documents. These are documents that you or your doctor will have so you will need to collect them yourself or speak with an attorney who should be able to assist you:
- Your notes and medical documentation about whether or not you ever received the recommended treatment, you received alternative less effective treatment, or you received no treatment at all because you could not afford it.
- A complete copy of your medical records related to the subject medical condition for which treatment was recommended and coverage was denied.
These steps will help an attorney decide whether he or she can move forward with a lawsuit. Once that is decided, there is much work to be done and a lot more information that the attorney will need but don’t worry about that yet. Just collect the records above and let the attorney sort it out.
ERISA Covered Medical Insurance Policies
ERISA: The Bad News
In the infinite wisdom of Congress, people who obtain their insurance, through their employers (other than governmental or religious institutions) which is most Americans with health insurance, have virtually no recourse for bad faith denial of medical coverage. Congress has basically baked into the law incentives for health insurers to cheat their policyholders in their time of greatest need. Our only advice for folks with ERISA based policies is to start raising hell now with their congressional delegation to change the law. If you get sick and your coverage is denied, it is far too late at that point. You are probably out of luck and out of time.
ERISA: The Good News
Most medical insurance in New Mexico is not going to be subject to ERISA due to the high number of government workers.
Governmental Workers are not covered byERISA:
This is very good news for New Mexico where 23% of the workforce works for either local, state or federal governmental entities. These workers have full rights to sue for medical insurance bad faith denial of coverage.
Call Us – We Feel the Same About Insurance Companies as You!
The lawyers at Collins & Collins, P.C. have been handling medical related issues for 20+ years. We began helping patients injured by hospitals. We still help those folks. In 2018, we turned our sights on prison medical atrocities. Interestingly, these cases are very similar to bad faith fraudulent denial of coverage for critical medical care. In fact, similar processes are in play with the goal of denying prisoners medical care just as in the insurance industry’s goal of denying coverage whenever until they get caught. And again much like bad faith denial of medical coverage, it doesn’t matter if they get caught once or repeatedly, they simply will not change as long as it is profitable.
Since 2018, we have filed 60 lawsuits against massive prison medical contractors who are basically just the bottom feeders of the HMO industry. We know how to deal with these companies and we know how to deal with your corrupt, greedy and malevolent insurance company.
Give us a call. As you may have gathered by now, we do not like corruption, we do not greed at the expense of patients and we do not like corporate bullies preying on the weak and vulnerable. And there is nobody more weak and vulnerable that when they are sick and/or dying and they are denied care by their insurance company who they have paid and trusted to do the right thing in their time of need.