insurance company denying valid claim situation

Quick background on my situation — any input appreciated.

insurance company denying valid claim. I've been dealing with this for about 10 months now and the situation isn't improving.

I have already consulted briefly with a lawyer but the other party is not cooperating.

What are my legal options here? Is it worth pursuing?

After exhausting internal appeals, you have the right to an external review under the ACA. This is done by an independent review organization (IRO) that is NOT affiliated with your insurer. Request it in writing within 4 months of the final internal denial.

External reviews overturn insurance denials roughly 40-60% of the time, especially for pediatric developmental services where the medical necessity evidence is clear.

Additional strategies:

• State insurance commissioner complaint: File simultaneously with the external review. Regulators investigate patterns of denial.
• Mental health parity: If speech therapy is classified as a mental health/behavioral health service under your plan, the Mental Health Parity and Addiction Equity Act may apply — meaning the insurer can't impose stricter medical necessity standards than for comparable medical/surgical benefits.
• Letter from treating physician: Have your child's therapist and pediatrician write detailed letters explaining why the service is medically necessary, citing clinical evidence and the child's specific diagnosis.

If the external review also denies, you can sue under ERISA (employer plan) or state insurance law (individual plan). For a child with a documented diagnosis and physician referral, these cases are sympathetic and many attorneys take them on contingency.