My client was injured in an automobile accident. After exhausting his PIP benefits, he was advised he needed neck and back surgery. My client paid $25,000 to his surgeon and the surgery center for his surgery. He submitted the surgery charges to his health insurer for reimbursement.
Instead of paying the bills, the health insurer repeatedly advised my client he had to resubmit the claim forms and bills. They also advised him that he needed to submit various other items of information before they could consider reimbursing him for his medical bills. After 8 months of submitting and resubmitting the requested information, my client gave up and retained counsel.
As you would expect, the insurance policy requires the health insurer to pay for all “medically necessary” care. The policy does not requires that the insured repeatedly resubmit his claim forms and bills. Nor did the policy require that the insured submit the other information which it was requesting from my client (although he did submit this additional information).
By failing to reimburse my client for his medical claims, the health insurer breached the terms of the policy. Yesterday, I filed a breach of contract case against the health insurer.
As with many of my insurance cases, there are no out-of-pocket expenses for my client. If I win, the insurance company will have to pay my fees and costs, and if I lose, I’ll work for free.