Insurance relied on outdated language to deny my prior authorization (PA). The specific wording used for the denial was removed on November 19, while my appeal was still under review. I received a response to my appeal on November 23, which upheld the denial based on the original language that had been eliminated just days prior (UHC acknowledged this to my broker after I brought the revision to my attention).
Do I have a strong case for legal action? I’ve tried to settle this issue directly with them, but without success.
I’m not a lawyer, but it sounds like you may have a valid case worth pursuing, especially since the insurer relied on outdated language that was removed shortly before they upheld your denial. Here are a few points to consider:
Breach of Contract: If the insurer based their denial on language that was no longer applicable, you may have a claim for breach of contract. Policies typically have to adhere to the terms in effect at the time of the appeal.
Bad Faith: If you can demonstrate that the insurer acted in bad faith by using outdated information, there may be grounds for a bad faith lawsuit.
Administrative Remedies: Before pursuing litigation, ensure you’ve exhausted all administrative remedies, including any appeals and reviewing the option for further internal review with the insurer.
Legal Advice: It may be beneficial to consult with a lawyer who specializes in insurance disputes to assess the specifics of your situation and provide you with tailored advice on how to proceed.
Documentation: Keep thorough documentation of all communications with the insurer and any revisions to the plan language, as this will be crucial if you decide to take legal action.
While you definitely have some compelling points, consulting with a legal professional will give you a clearer picture of your chances and options.