Do I have a bad faith insurance claim if my insurer denied me effective treatment?

UPDATED: Oct 1, 2022

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Do I have a bad faith insurance claim if my insurer denied me effective treatment?

About 9 months ago, I was diagnosed via colonoscopy and biopsies with advanced, severe Crohns disease. At that time, my GI advised that I start a biologic medication immediately due to the severity of my disease. However, my insurance company denied my claim for the medication and wouldn’t even talk to my GI to allow her to appeal. They demanded I try several types of medications including steroids before they’d consider approving the biologic. My GI already knew that they wouldn’t work so for 4 months I was essentially untreated. In that time I was hospitalized and had 2 surgeries due to a perforated small bowel and abscess. My insurance company didn’t even attempt to investigate my claim or talk to a medical professional regarding it. I am wondering if I have any recourse. Had they approved the medication back when first prescribed, I am certain that I would not have gone through 5 months of suffering, surgeries and hospitalization. I am still recovering from the last surgery.

Asked on February 4, 2018 under Malpractice Law, New Hampshire


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 4 years ago | Contributor

You most likely do not have a claim. Your insurer is not your doctor; your insurer does not provide or prescribe medical care, and cannot stop you from getting it, such as by paying out of pocket. All the insurer does is pay or not pay for certain treatment, according to the terms of your policy. When they should pay but don't, you can pay yourself and then sue them to get the money they should have paid out--so is there recourse when the insurer doesn't honor its obligations, but that recourse is for the money they should have paid. Because the insurer does not prevent medical treatment and you could, as stated, have paid or it or arranged for it some other way, they are generally not liable for any consequences of delaying treatment, since again, they did not actually stop you from getting it.

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