Our client discovered they had been consistently overpaying on their family health insurance premiums for years due to an incorrect, higher-risk classification that was never adjusted after a qualifying life event. The insurance company acknowledged the error but offered only a minimal refund for the most recent 12-month period, citing complex internal policy language and a statute of limitations defense.
They argued that premium reconciliations were the client's responsibility to audit annually. The challenge was to recover the full overpayment across the entire duration, as the client had relied on the insurer's billing statements in good faith, suffering a significant and ongoing financial loss.
We overcame this by shifting the argument from a simple billing error to one of breach of contract and unjust enrichment. We meticulously audited seven years of premium statements against the actual policy terms and the client's documented eligibility status. We then paired this financial analysis with a legal strategy that challenged the enforceability of the insurer's one-year lookback clause under state consumer protection laws, arguing it was unconscionable in a relationship of unequal knowledge and power.
By demonstrating the insurer's systematic failure to apply its own rules and the substantial, quantifiable detriment to our client, we created powerful leverage. This compelled the insurer to agree to a confidential settlement that provided a full refund of all verifiable overpayments plus a significant additional sum, avoiding the risk of a public class-action precedent.
Result: Our client received a substantial lump-sum payment covering years of overcharges, achieving financial restitution and correcting the policy's classification moving forward.
