We were successful in achieving a settlement on behalf of a woman who was a member of a local HMO. After finding out that she needed extensive oral surgery, she asked the HMO if she was covered. The policy she had been issued clearly covered the surgery and her doctors advised the HMO that the surgery was necessary. The HMO, however, denied the coverage and offered as its excuse that their claim manual said the surgery was not covered. Before filing suit, we pointed out that the claim manual and the insurance policy were different and that in this case the policy should rule (after all, this is what the customer paid for.) The HMO still declined to pay for the surgery.
We filed suit under a Virginia law that allows a patient to sue the HMO and ask the court to read the policy to determine who was right. That law allows a patient to recover her attorney's fees if she is successful. As soon as the HMO's lawyers read the lawsuit they called up and offered to settle the case. The realized that the claims adjuster was completely wrong. The surgery was authorized and the company agreed to pay all of the attorneys fees.
Our experience is that insurance companies and HMO's routinely deny claims unjustifiably. They know that only about 1 person in 25 will go to an attorney and they know that there are not that many attorneys who will take these insurance denial cases. Even though they paid in this case there are countless others in which the patient has not fought for her rights.