The insurance company relied on outdated and obsolete plan language to justify their denial of my prior authorization (PA). The specific language used to deny my PA was removed from the plan on November 19, while my appeal was still under review. However, I received a response to my appeal on November 23, which upheld the original denial based on the language that had already been removed on November 19. United Healthcare confirmed this to my broker after I flagged the revision on my portal.
Am I justified in considering legal action? I’ve tried to resolve this directly with them without success.
It sounds like you have encountered a potentially valid issue with your insurance provider’s handling of your prior authorization (PA) appeal. The fact that they based their denial on outdated language that was officially removed prior to your appeal decision is a significant point in your favor. Here are a few aspects to consider if you’re thinking about legal action:
Documentation: Gather all relevant documentation, including the initial denial letters, your appeal, the communication with your broker regarding the plan updates, and any supporting evidence that shows the language change.
Legal Grounds: Consult with an attorney who specializes in insurance law. They can assess whether you have a strong case based on breach of contract, bad faith insurance practices, or violations of state or federal regulations.
Insurance Regulations: Familiarize yourself with your state’s insurance regulations as well as any relevant federal regulations (like ERISA, if applicable). These rules may provide further support for your case.
Alternatives: Before pursuing a lawsuit, consider other avenues. Sometimes mediation or filing a complaint with your state’s department of insurance can lead to a resolution without the need for litigation.
Cost vs. Benefit: Keep in mind that lawsuits can be costly and time-consuming. Weigh the potential benefits of winning your case against the costs involved.
In summary, while you may have a good foundation for a lawsuit based on the insurance company’s use of outdated language, it’s important to consult with a legal professional who can guide you through the process and assess the strength of your case.