What to do if my health insurer has denied benefits for my son?

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What to do if my health insurer has denied benefits for my son?

My son had a lot of dental work to be done and due to his anxiety the dentist recommended him to have anesthesia for the procedure. United health care paid for dental work but have denied the anesthesia bill. Originally the doctor estimated 2 hours but it turned out to be 6 hours for $5,000. United health care denied 2 appeals several reasons contradicted themselves. I filed an application with the NJ department of banking and insurance. Now I get a letter from Oxford with a different review and different reason. This has been going on for over a year. Wasting my time and energy and emotionally upsetting.

Asked on June 13, 2019 under Insurance Law, New Jersey

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 1 year ago | Contributor

If you believe, as you evidently do, that the denial of benefits was wrong--that is, that under the plain terms of the policy, which is a contract, the insurer should have paid--you could sue the insurer for "breach of contract" for the money. If you prove in court that under the policy they should have paid, the court can order them to do so. That, a private lawsuit, is the only other option you have beside what you have already done: trying to work through the state's dept. of banking and insurance. Unfortunately, lawsuits have their own costs--for example, the cost of an attorney, unless you were comfortable representing yourself "pro se"--and you could spend as much or more on the suit than you hope to get back, with no guaranty of success (no lawsuit is ever guaranteed; do not believe any lawyer who ever tells you success is certain). Therefore, while you have the option of a lawsuit, it is not a very good option; you may not have anything you can effectively do but stay the course and see if the dept. can help you.


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