Thank you for your question and I'm sorry to hear about this situation.
You are correct in your assessment. The insurance company cannot deny your claim where you have in fact acted as a reasonably prudent person in seeking and obtaining treatment of the condition.
When insurance has been wrongly denied based on a misapplication of an exclusion under the policy, the insurance company has committed a breach of contract. Often, the insurance policy requires that you go through an appeal process. However, you can often file suit in lieu of completing the appeals process where you believe that the insurance company is simply acting in bad faith.
These sort of lawsuits can be very complicated and you will need to hire an attorney. A personal injury attorney is the best type of attorney to hire in this sort of claim. There are several that specialize in insurance claims and may be able to take your case on a contingency basis (without any up front cost to you).
Getting an attorney involved may also speed up the process of getting your claim paid even if it is through the internal appeal process.
Please let me know if you have any questions regarding my answer.
should i proceed with my appeal letter as a first try or try to find legal representation and forget the appeal letter
This really depends on whether you are going to want to take the risk of paying an attorney when you might be able to get the claim paid on your own. Remember, the attorney will likely take a case like this on contingency, which means that you might have to pay the attorney 35-45% of whatever you end up getting from the insurance company.
This is generally seen as pretty significant, so I would suggest going ahead with the appeal. I would also suggest going ahead and setting up some appointments with a few different attorneys to see if they would be interested in representing you if the appeal does not end favorably for you.
wow that much huh? this is only a $10,000 claim and I was hoping to use the money to help pay for medical costs of surgery
Ok thanks, XXXXX XXXXX submit my letter of appeal to them first. can I forward you my letter to see if there are any words i can add to make it more assertive or can you suggest any phrases I can add to make it more aggressive.
Please send the letter to: firstname.lastname@example.org as an attachment. IN the email, put the link to this question: http://www.justanswer.com/law/7kp4g-purchased-first-diagnosis-cancer-insurance-plan.html
And ask that the attachment be forwarded to zdnlaw.
my e-mail would not allow me to send, viewed link as spam, so i sent it via my son's email
I'll keep a look out for it. It may take some time to get to me, so thanks in advance for your patience.
Sorry for the long wait. I finally received your email and reviewed your letter. I've made some changes and have copied and pasted the text below for your review.
February 18, 2013
Claimant: Maria R. Lopez
Attention Health Claims:
I write this letter to formallynotify you that I dispute and protest the Insurer's denial of my claim forbenefits under the above-referenced policy.
Insurer has denied myclaim based on a review of my medical records obtained from Dr. Lourdes Concha,my primary treating physician. Based on these records, the Insurer determined thatthe cancer for which I am claiming coverage was the result of a pre-existing conditionfor which I did not obtain reasonable medical treatment. However, the medical records clearly showthat the Insurer failed to properly analyze my claim and is wrongfully denyingmy claim.
The medical recordsindicated that I was being seen for a nodule on my thyroid as far back as 2009,this is correct. Your letter also statesthat I had ultrasounds that showed the nodule had increased in size over theyears, this is also correct. However,your analysis fails to include the fact that I had numerous biopsies performedbetween 2009-2012 in order to monitor the nodule for cancerous growth. These biopsies and scans, along with themedication, Levothyroxine, were necessary precautions taken by a prudent personwith a nodule on her thyroid. The negativebiopsy results, scan results, and thyroid functioning normal, were taken intoconsideration in order to avoid unnecessary surgery.
After biopsies conductedwere negative to cancer, but the nodule continued to increase minutely, Dr.Concha recommended removal of right side of thyroid and proceeded to make anappointment with surgeon Dr. Tan Nguyen during my July follow-up appointmentwith my consent. The appointment wasmade by her assistant for the next available appointment which was inNovember. I proceeded with theappointment, gave the referral listed by Dr. Concha as removal of right side of thyroid fornontoxic unimodular goiter to Dr. Nguyen. After Dr. Nguyen gave me dates he had available for surgery in December,January, and February, we set the surgery day for December 10, 2012, tocoincide with Christmas vacations and help in the recovery time.
Again, I was referred fora partial thyroid removal because of previous negative results of scans and cancerbiopsies. If I had a pre-existing cancerdiagnosis or had been given advice for cancer or treatment as your definitionstates in your letter, I would have been recommended for a full thyroidremoval. On the contrary, I was NEVERdiagnosed with cancer as a result of the constant, reasonable and prudentmedical treatment I received for this condtion until the recent surgery. I took every precaution in monitoring nodule,had thyroid scans in order to monitor growth, took medication in order to tryand stop growth, submitted myself to several painful biopsies which were allNEGATIVE to cancer, and proceeded with referral to remove right side of thyroidwith certified surgeon Dr. Tan Nguyen when it was deemed necessary.
I am resubmitting thelatest report (7/23/12) from Dr. Concha's office and highlighting herassessment which shows her referral to a surgeon for a nontoxic nodular goiter,that the right thyroid nodule is negative for malignancy, and that the thyroidwas functioning normal and surgery to be done in December. Please contact her office if you need anyfurther clarification.
I demand that youreevaluate this claim and review the policy that I purchased with yourcompany. I did everything a prudentperson should have done and I would hate to think that your company is actingin bad faith in not fulfilling the contract.
Awaiting your reply,
Maria R. Gomez-Lopez
Please let me know if you have any further questions. Please also remember to rate my answer positively as I will not be compensated for my time and work on your question until you do so.
DISCLAIMER: Answers from Experts on JustAnswer are not substitutes for the advice of an attorney. JustAnswer is a public forum and questions and responses are not private or confidential or protected by the attorney-client privilege. The Expert above is not your attorney, and the response above is not legal advice. You should not read this response to propose specific action or address specific circumstances, but only to give you a sense of general principles of law that might affect the situation you describe. Application of these general principles to particular circumstances must be done by a lawyer who has spoken with you in confidence, learned all relevant information, and explored various options. Before acting on these general principles, you should hire a lawyer licensed to practice law in the jurisdiction to which your question pertains.
The responses above are from individual Experts, not JustAnswer. The site and services are provided “as is”. To view the verified credential of an Expert, click on the “Verified” symbol in the Expert’s profile. This site is not for emergency questions which should be directed immediately by telephone or in-person to qualified professionals. Please carefully read the Terms of Service (last updated February 8, 2012).