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Ask Law Educator, Esq. Your Own Question
Law Educator, Esq.
Law Educator, Esq., Lawyer
Category: Consumer Protection Law
Satisfied Customers: 111496
Experience:  Attorney experienced in commercial litigation.
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I have Trustmark accident insurance. I had an accident in

Customer Question

I have Trustmark accident insurance. I had an accident in February that eventually required surgery. I went to a number of doctors and was under care continuously. The goal was to avoid surgery but finally surgery was required.
The surgery is covered under the accident plan, however, the claim was denied because the surgery was not done within 90 days.
Do I have grounds to appeal the denial as I was under care the entire time and all of the physicians determined the injury was due to the accident and the documentation was included with the initial claim package. In addition, some delay occurred as the original surgeon declined the surgery as "too complex" and sent me to a specialist who retired his own exam and tests etc.
Submitted: 1 year ago.
Category: Consumer Protection Law
Expert:  Law Educator, Esq. replied 1 year ago.

Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.

Denial of a claim because surgery was not done in 90 days, when the plan states such surgery is covered, is likely to be deemed a bad faith denial when the claimant was under continuous medical care for the covered injury. You need to send them a letter informing them that you have been under continued care of a licensed medical professional and surgery was a "last resort" treatment and it has now come to that. Tell them in the letter that their denial of the claim for not having surgery in 90 days when the policy does not state that is a bad faith denial of your claim and if they refuse to reconsider and approve the claim, you will be forced to sue them for breach of contract in bad faith and seek your damages plus punitive damages and attorney's fees for their bad faith denial of your claim. If they refuse your appeal, then you have a basis (presuming the contract does not say surgery has to be performed in 90 days from claim) to file suit against them and seek damages from them for their breach and bad faith.