Claim Denials for Individually Purchased Insurance Policies
Differences Between Individual and Employer-Provided Insurance
Has your insurance company denied your claim? Unfortunately, this happens far too often. Sometimes, the denial is in bad faith because an insurer does not uphold its obligation under the policy to pay the full benefits it allows. Insurance companies make the protection of profit their primary goal; to do so, they sometimes act in bad faith. In addition to outright denial of a valid claim, there are other ways in which an insurance company may act in bad faith. It may delay or underpay your claim, putting an unnecessary financial burden on you when you should have the full benefits defined in your policy paid to you in a timely fashion.
When we discuss and insurance “policy” we address insurance coverage that is purchased by you as an individual. This differs from an employer-sponsored “plan” in which your benefits are available through coverage purchased by your employer.
Types of Individual Insurance Denials We Handle
At Kantor & Kantor, we have helped thousands of clients whose claims were unfairly denied, for a range of insurance types. The most common claim denials we see relate to disability benefits, long-term care, or when our client loses a loved one and faces denial of a life insurance claim. In addition to life insurance, other cases we often handle involve these types of individually purchased insurance: health, long-term disability, and long-term care.
When you experience a claim denial and you believe it was unjust, you may have legal options to fight it. Insurance companies count on policyholders’ not fighting back. Don’t give up – get help. Call our attorneys at Kantor & Kantor at 818-886-2525 today.
Does ERISA Govern Your Insurance Coverage?
If Your Insurance Is Through Your Employer, ERISA Applies
One important difference between individually purchased and employer-sponsored insurance lies in which laws govern when a claim is unjustly denied, underpaid, or delayed. When you are a member of a plan provided through your employer, the rules within the Employee Retirement Income Security Act (ERISA) apply1. This federal legislation sets out an extensive and highly complex set of rules that govern how a case can proceed when an insurance company wrongly denies a claim. ERISA imposes limitations upon the claim process, and working with an attorney who has extensive knowledge of this law and ERISA case precedents will be to your advantage.
Some of the ways in which an ERISA case differs from a case involving an individually purchased policy are:
- For an ERISA claim, you must appeal your case through the plan’s claim administrator before you can litigate it. In short, you cannot go to court without first submitting an appeal of a claim denial.
- Only the information provided to support your appeal will be considered in the next step, which is taking your case to trial.
- The standard of review in an ERISA case may mean the Court provides a plan administrator discretion to determine whether or not to pay benefits.
- In a court case involving ERISA, the decision is made by a judge, not a jury.
- Damages available in an ERISA case are limited to the benefits you were due and attorney fees. You cannot receive compensation for emotional distress or punitive damages.
State Laws Govern Individual Insurance Claim Denials
When you purchase your insurance coverage individually, legal issues related to your individual policy are governed by state law. While state laws can be less complex than ERISA, they are nonetheless detailed and require specialized experience to understand them. Just as with federal cases, knowledge of past cases in a particular state can help an attorney to successfully argue your case. Unlike federal cases governed by ERISA, you can take your bad-faith denial straight to court for a jury trial if you have an individually purchased policy.
Insurance laws differ from state to state, so you need an attorney who understands applicable state law to fight for you if your insurance claim was unfairly denied. Kantor & Kantor helps clients throughout the country. Find out how we can help you.
Common Types of Individual Insurance Claims
Some people do not have insurance available through their employer – perhaps because they are contract workers or part-time workers whose weekly hours do not meet the threshold to receive employer-sponsored coverage. The most common types of insurance bad-faith cases Kantor & Kantor handles for individually purchased policies relate to health insurance, long-term disability, long-term care, and life insurance. However, our attorneys handle a range of case types in addition to these.
Which State’s Laws Apply to Your Case?
While you may assume that the laws of the state in which you live apply when your insurance claim is denied, that may not always be the case. There are times when a policy is purchased in one state and the policyholder then moves to another. It is possible that the laws of the state in which a policyholder resided at the time of purchase are what will govern a legal dispute regarding a claim denial.
Kantor & Kantor Is Your Best Option for Legal Representation
We Help People Nationwide Who Have Insurance Claims Wrongly Denied
When an insurance company treats you unfairly, you may have a legal path to getting your claim fully and promptly paid. Don’t let an insurance company get away with a claim denial, delay, or underpayment. You deserve the full benefits your policy allows. Kantor & Kantor zealously fights for our clients to obtain those benefits.
- We have an extensive history of victories in bad-faith cases when insurers have not upheld their duties under the policy contract. We know in detail the many ways an insurer can act in bad faith, and our strategies to win these cases help us succeed.
- Our attorneys have decades of experience in a range of bad-faith cases. Insurance cases can be complex, requiring not only experience with that area of insurance but also detailed knowledge of state and federal laws.
- We are fierce litigators, unafraid of taking a case to trial, and insurance companies know this. Court battles cost insurers a lot of money, and the risk of loss for them is substantial when they face Kantor & Kantor. This makes them more willing to avoid court by giving you a fair settlement.
- We aren’t quick to settle. When insurance companies are ready to negotiate to avoid a court case, we always fight for the best possible outcome. Other law firms may prefer to close a case quickly. At Kantor & Kantor, obtaining the full benefits you deserve is our primary goal.
- We are people helping people. Our team understands the stress that a denied claim brings. We put our legal expertise to work for you, but we also have compassion for you in this difficult time. Our client reviews speak to how we treat clients.
If you need legal representation, turn to our attorneys at Kantor & Kantor. There is good reason that we are the firm other lawyers and judges turn to for help. Call 818-886-2525 today.
Learn how we can help you with any of the below types of claims:
Types of Remedies Available in a State Insurance Bad-Faith Case
Damages You Can Win in a State Trial
A legal “remedy” is compensation you can receive if you win your bad-faith case at trial. These remedies may also be called “damages” and are payments you can receive if you are victorious in court. Among the types of remedies that you could potentially be awarded are:
- Full payment of the claim
- Depending on the type of insurance, that may include coverage of medical bills, in-home care, occupational therapy, and lost wages, among other items.
- You may be able to pursue an amount that exceeds the benefits owed by your policy. For example, if you live in Colorado, you can receive “two times the covered benefit” (C.R.S. § 10-3-1116(1)).2
- Attorney fees
- Damages for pain and suffering or emotional distress.
- Punitive damages
Depending on the state where your claim is litigated, there may be caps on the damages you can win. For example, in Georgia, an insurer can be required to pay the full benefits a policy allows and up to 50% of the loss you suffered or $5,000, whichever is greater (O.C.G.A. §33-4-6)3. Many states do not impose this type of limitation.
“Contractual damages” are losses specific to the financial benefits your insurance policy offers. If you win your bad-faith case, your claim should be paid, and you may also receive interest on that amount. One element unique to a state legal case is “extra-contractual remedies.” These are the damages recoverable from an insurer that are in addition to the payment of your claim. The above-mentioned attorney fees, damages for emotional distress, and punitive damages are examples of extra-contractual remedies.
Learn about potential legal remedies in your situation by getting a case evaluation from one of our attorneys at Kantor & Kantor. We are located in california, but we may be able to help regardless of the state in which you live. We serve clients throughout the country.
Damages for Emotional Distress
Depending on your situation, the unfair denial of your insurance claim may cause you anxiety, worry, or anguish. Many states – including California — allow a plaintiff to seek compensation for these damages (CACI 3905A)4.
Your ability to seek compensation for having suffered emotional distress resulting from the unfair denial of a claim will depend upon the state in which your case is litigated. In addition, some states place limits on the damages you can seek in a bad-faith case, including caps on compensatory damages, similar to those for emotional distress. California is one of the many states that allow you to pursue damages for emotional distress.
Punitive Damages in a Bad-Faith Case
When an insurance company acts particularly egregiously by denying payment of your claim or even delaying or underpaying it, a Court might award you punitive damages, sometimes called “exemplary damages.” Each state’s statutes define which actions merit punitive damages. Punitive damages are designed to make a cautionary example of an insurance company, with the intent of preventing other insurers from acting in the same way. Some states may not allow punitive damages unless you suffer physical injury. In addition, states may have limits, or “caps,” on the amount of punitive damages a plaintiff can seek.
Awards of punitive damages are rare, The burden of proof is high: the evidence must be clear and convincing that an insurer acted in an egregiously harmful way.
Exemplary damages are available in California. In this state, exemplary damages are available in cases where there is clear and convincing evidence that an insurer is “guilty of oppression, fraud, or malice” (CA Civ. Code § 3294 (a))5. In some cases, an insurance company may deny a claim that it knows it should pay, even when that may mean the insured will go without life-saving treatment. This can constitute “oppression” which California law defines as “despicable conduct that subjects a person to cruel and unjust hardship in conscious disregard of that person’s rights” (§ 3294(c)(2)).
The Remedies You Seek in Your State May Not Be Set in Stone
What remedies are allowed under state laws in a bad-faith case are not set in stone. State legislators may change laws and expand the types of damages you can seek in a case. Or the ways in which state courts apply the laws may set new precedents and allow you to pursue damages that were not previously available.
Oregon provides a representative example. As of 2023, insureds have not been able to seek extra-contractual damages in Oregon. Legislators hoped to pass a law to rectify that (HB 3242)6, but it failed. However, change can happen via case law when it does not happen via legislation. With a case that could come before the Oregon Supreme Court, awards of extra-contractual damages may become a possibility if the plaintiff prevails (see Moody v. Oregon Community Credit Union and Federal Insurance Company)7.
Our attorneys at Kantor & Kantor are fierce litigators with extensive experience in court. We will fight for the best outcome possible in your case.
When you take on your insurer in state court for an act of bad faith, typically, you can expect payment of your claim if the Court finds in your favor. While a few states do not allow a plaintiff to recover damages for emotional distress or punitive damages, most will allow you to pursue compensation for financial damages when your benefits were denied (and sometimes up to an amount that is a multiple of those damages). Likewise, most will also allow you to seek payment of your attorney’s fees as a legal remedy.
Don’t Give Up. Get Help.
Trying to go it alone in a battle with your insurance company to pay for your unjustly denied claim is an uphill fight. Insurance companies count on policyholders to give up when facing the complex battle over denying their unfair claims. However, ceding that battle can result in a large and unnecessary loss to you. A lot can be at stake in a bad-faith legal case, and having a top-notch attorney at your side is essential. When you work with Kantor & Kantor, you can rest assured that you have highly skilled and deeply experienced insurance attorneys representing you. Let’s talk about your case today. Call us at 818-886-2525 for your free case evaluation.
Sources
1 Employee Retirement Income Security Act of 1974. [Public Law 93-406] https://www.govinfo.gov/content/pkg/COMPS-896/pdf/COMPS-896.pdf
2 Colorado Revised Statutes. Chapter 422. Insurance. C.R.S. § 10-3-1116. https://leg.colorado.gov/sites/default/files/images/olls/2008a_sl_422.pdf
3 Georgia Insurance Code § 33-4-6. Liability of insurer for damages and attorney’s fees. https://law.justia.com/codes/georgia/2010/title-33/chapter-4/33-4-6
4 California Civil Jury Instructions. No. 3095A. Physical Pain, Mental Suffering, and Emotional Distress (Noneconomic Damage). https://www.justia.com/trials-litigation/docs/caci/3900/3905a/
5 California Civil Code. Article 3. Exemplary Damages. https://leginfo.legislature.ca.gov/faces/codes_displaySection.xhtml?sectionNum=3294.&lawCode=CIV
6 82nd Oregon Legislative Assembly – 2023 Regular Session. House Bill 3242. https://olis.oregonlegislature.gov/liz/2023R1/Downloads/MeasureDocument/HB3242/B-Engrossed
7 Christine Moody v. Oregon Community Credit Union and Federal Insurance Company 371 OR App 233 (2022) https://www.uschamber.com/assets/documents/Lower20Court20Opinion20-20Moody20v.20Oregon20Community20Credit20Union2028Oregon20Court20of20Appeals29.pdf
Attorney Glenn R. Kantor
Glenn Kantor is a founding partner of Kantor & Kantor LLP. As a young attorney, Glenn saw the injustice of wrongful insurance denials and created a law firm to represent individuals seeking to obtain their rightful benefits. Glenn is committed to ensure that clients receive the benefits they are entitled to under their insurance policies or group health plans. [Attorney Bio]
