Suppose your health insurance company denies coverage for a medication you need. In that case, it can feel unfair and even frightening—especially if that medicine is essential for your health. The good news is, in some cases, you can sue your health insurance company for denying medication—but the process depends on why the medication was denied and what steps you take first.
Understanding Why Insurance Companies Deny Medications
Before jumping into a lawsuit, it’s important to understand why your insurance company denied coverage. Common reasons include:
- The medication isn’t on your plan’s formulary (approved drug list).
- The insurer believes there’s a cheaper alternative available.
- The drug is deemed “experimental” or “not medically necessary.”
- Paperwork or pre-authorization wasn’t completed correctly.
- The prescription is being filled too soon or exceeds dosage limits.
Knowing the reason for denial helps you determine whether it’s a clerical mistake, a misunderstanding, or a more serious issue of bad faith.
File an Internal Appeal
In most cases, you must first appeal the denial internally through your insurance company before taking legal action. Every health insurance provider is legally required to have an appeal process.
During this step, you (or your doctor) can submit additional documentation—such as medical records or letters of medical necessity—to prove why the medication is essential to your treatment.
If the appeal succeeds, you’ll get your medication without further action. But if it’s denied again, you can move to the next step.
Request an External Review
If your internal appeal is denied, you have the right under federal law to request an external review. This means an independent third party—not employed by your insurer—will review your case and decide if the insurance company’s decision was justified.
External reviews are binding, meaning if the reviewer overturns the denial, your insurer must cover the medication.
When You Can Sue Your Insurance Company
If both your internal appeal and external review fail—or if your insurer acted in bad faith—you may have grounds to sue. “Bad faith” means your insurance company:
- Ignored clear medical evidence or your doctor’s recommendations.
- Delayed responses or refused to process your claim.
- Misrepresented what your plan covers.
- Denied coverage without a valid reason.
In these cases, you can sue for breach of contract or bad faith insurance practices, and possibly recover financial compensation for damages, stress, or additional medical costs.
What You Can Sue For
If a lawsuit becomes necessary, you may be able to seek compensation for:
- The cost of the denied medication.
- Out-of-pocket expenses you had to pay.
- Emotional distress caused by the denial.
- In extreme cases, punitive damages if the insurer acted maliciously or fraudulently.
However, insurance lawsuits can be complex, so you’ll need a lawyer experienced in health insurance or bad faith cases to guide you.
When to Hire an Attorney
You should contact an attorney if:
- Your medication denial is upheld after an appeal.
- Your insurer ignores or delays your appeal.
- The denied medication is life-sustaining or medically critical.
- You suspect discrimination or an unfair claims process.
An attorney can evaluate your plan, correspondence, and medical documentation to determine if you have a valid lawsuit—and handle negotiations or litigation on your behalf.
Protecting Yourself in the Future
To prevent issues with medication denials, take these proactive steps:
- Understand your plan’s formulary – Know which drugs are covered and what rules apply.
- Work with your doctor – Ensure they submit detailed documentation and prior authorization when needed.
- Keep written records – Save all communications with your insurer, including emails, appeal letters, and call logs.
- Know your legal rights – Under the Affordable Care Act, you have the right to appeal any coverage denial.
Final Thoughts
Yes—you can sue your health insurance company for denying medication. Still, lawsuits are typically a last resort after going through the required appeal and review processes. If your insurer acts in bad faith or unfairly denies vital treatment, you have legal options to hold them accountable.
When in doubt, consult an attorney who specializes in insurance law. They can help you understand your rights, navigate the appeals process, and fight for the coverage—and care—you deserve.