If my insurance company not following their own policy, what do I do?

UPDATED: Sep 30, 2022

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If my insurance company not following their own policy, what do I do?

I am a female-to-male trans individual. Recently, my health insurance company enacted a new policy that’s more trans-inclusive, meaning that top surgeries are now completely covered. I went through the process of going through my doctor and my therapist. Both referred me for top surgery and said I qualified for it. I submitted my referral to my insurance. I was promptly denied because they were still operating under the old policy, and not the new policy. I am now being told to appeal their decision. What can I do if they continue to refuse to follow their own new policy?

Asked on November 22, 2016 under Insurance Law, South Carolina


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 6 years ago | Contributor

You can sue them: an insurance policy is a contract, and contracts are enforceable in court. If you believe that under the terms of the insurance policy and the circumstances as they exist, they are obligated to pay, you could sue them for breach of contract (violation of the policy) in county or possibly federal court (if the amount is high enough--over $50k in projected medical costs--and they are located in a different state). You do need, however, to check the terms of your policy, to see if it obligates you to either use arbitration rather than suing, or to sue in a specific court; such contractual terms, defining how and where you can take legal action, are enforceable.

IMPORTANT NOTICE: The Answer(s) provided above are for general information only. The attorney providing the answer was not serving as the attorney for the person submitting the question or in any attorney-client relationship with such person. Laws may vary from state to state, and sometimes change. Tiny variations in the facts, or a fact not set forth in a question, often can change a legal outcome or an attorney's conclusion. Although AttorneyPages.com has verified the attorney was admitted to practice law in at least one jurisdiction, he or she may not be authorized to practice law in the jurisdiction referred to in the question, nor is he or she necessarily experienced in the area of the law involved. Unlike the information in the Answer(s) above, upon which you should NOT rely, for personal advice you can rely upon we suggest you retain an attorney to represent you.

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