The reason why this would work is because it makes it appear as though you may get lawyers involved. Yeah, they don’t want to pay out claims, but they also don’t want to get sued and lose. This is an intimidation check to make them either back down and pay out or risk potentially going to court with someone who appears to know what’s up. They’d rather just pay the bill at that point, at least as long as this doesn’t become common.
That might be the case if you got to talk to someone with the ability to do anything about it. Customer service is just able to tell you what happened, not really make any change. You can file an appeal, but you can’t really ask for much during that process. It’s mostly automated and the people who process those have very specific criteria for overriding an initial decision and have a very short period of time they’re allowed to spend on each appeal.
So the only way you’d get to someone who might be able to access any of this information is through a lawsuit. Trying to intimidate a worker with no power, no access to information, and a very high quotas is unlikely to have much effect. And these companies all have more lawyers on staff and/or retainer than any of us could afford in a hundred lifetimes. And those people aren’t going to give that information anyway. Nor would they give it to any lawyer you might hire in most cases. Proprietary information has way more legal protections than consumer rights, even in healthcare. You’d need to get a judge to order that release of confidential information about an employee or proprietary algorithm in most states, unless you convince someone to sacrifice their job, their freedom, and possibly their life to become a whistleblower.
So unless your claim is in the hundreds of thousands at least, it’s unlikely you’ll spend less on lawyers just to get your case in front of someone who can answer these questions much less compelled them to give it. Otherwise, they’d have an incentive to pay claims in good faith in the first place. So there’s no intimidation felt on their end by things like this. It just makes them get I to a defensive posture if anything, and likely reduces your likelihood of getting an appeal approved in a timely manner.
Your best bet if your claim is denied and appeal fails and you actually have a case is to hope you live in a somewhat progressive state that funds their insurance commission and has more consumer-friendly laws, and go to them for help. Federal laws aren’t going to help much unless you have evidence of fraud or you understand all the details of the case and can point to specific contract language or laws they violated already. But in that case the appeal should be all that’s needed.
I would add a caveat to your statement. It might not be just through a lawsuit but the threat of a lawsuit. A lawsuit will cost big money, but having a lawyer right the company a letter shouldn’t cost more than a couple of hundred bucks. Most people give up immediately and that’s what they are counting on. Worst case scenario is what? Tack a couple of hundred on to the thousands you will already owe? Basically a drop in a bucket.
Also, as scummy as the profession and some lawyers are, there are plenty who just want to do right by people. I have only paid a lawyer once, but I have talked to around half a dozen in my life time with questions about the law and some of the issues I was having. One or two probably spent at least a couple of hours on me over the course of a month or two when you factor in the initial 20-30 minute conversation, reading the documents I put together, and answering some of my follow up emails, and despite my insisting they charge me, they were insistent on not doing so.
(I suspect because in many of the situations what was happening to me was morally wrong, but legally more or less fine just barely grazing the gray area, and taking payment for their time could be construed as them acting as legal counsel as opposed to just answering some questions)
The reason why this would work is because it makes it appear as though you may get lawyers involved. Yeah, they don’t want to pay out claims, but they also don’t want to get sued and lose. This is an intimidation check to make them either back down and pay out or risk potentially going to court with someone who appears to know what’s up. They’d rather just pay the bill at that point, at least as long as this doesn’t become common.
That might be the case if you got to talk to someone with the ability to do anything about it. Customer service is just able to tell you what happened, not really make any change. You can file an appeal, but you can’t really ask for much during that process. It’s mostly automated and the people who process those have very specific criteria for overriding an initial decision and have a very short period of time they’re allowed to spend on each appeal.
So the only way you’d get to someone who might be able to access any of this information is through a lawsuit. Trying to intimidate a worker with no power, no access to information, and a very high quotas is unlikely to have much effect. And these companies all have more lawyers on staff and/or retainer than any of us could afford in a hundred lifetimes. And those people aren’t going to give that information anyway. Nor would they give it to any lawyer you might hire in most cases. Proprietary information has way more legal protections than consumer rights, even in healthcare. You’d need to get a judge to order that release of confidential information about an employee or proprietary algorithm in most states, unless you convince someone to sacrifice their job, their freedom, and possibly their life to become a whistleblower.
So unless your claim is in the hundreds of thousands at least, it’s unlikely you’ll spend less on lawyers just to get your case in front of someone who can answer these questions much less compelled them to give it. Otherwise, they’d have an incentive to pay claims in good faith in the first place. So there’s no intimidation felt on their end by things like this. It just makes them get I to a defensive posture if anything, and likely reduces your likelihood of getting an appeal approved in a timely manner.
Your best bet if your claim is denied and appeal fails and you actually have a case is to hope you live in a somewhat progressive state that funds their insurance commission and has more consumer-friendly laws, and go to them for help. Federal laws aren’t going to help much unless you have evidence of fraud or you understand all the details of the case and can point to specific contract language or laws they violated already. But in that case the appeal should be all that’s needed.
I would add a caveat to your statement. It might not be just through a lawsuit but the threat of a lawsuit. A lawsuit will cost big money, but having a lawyer right the company a letter shouldn’t cost more than a couple of hundred bucks. Most people give up immediately and that’s what they are counting on. Worst case scenario is what? Tack a couple of hundred on to the thousands you will already owe? Basically a drop in a bucket.
Also, as scummy as the profession and some lawyers are, there are plenty who just want to do right by people. I have only paid a lawyer once, but I have talked to around half a dozen in my life time with questions about the law and some of the issues I was having. One or two probably spent at least a couple of hours on me over the course of a month or two when you factor in the initial 20-30 minute conversation, reading the documents I put together, and answering some of my follow up emails, and despite my insisting they charge me, they were insistent on not doing so.
(I suspect because in many of the situations what was happening to me was morally wrong, but legally more or less fine just barely grazing the gray area, and taking payment for their time could be construed as them acting as legal counsel as opposed to just answering some questions)