Legal aid and when to hire a lawyer

Look for free legal aid first, and think about hiring a lawyer when the next step is a hearing, a lawsuit or a debt lawsuit. Lawyers can read your plan document and tell you what applies to you. We give information here, not legal advice.

What this means

Legal aid means a nonprofit office that gives free legal help to people who qualify, often by income. In Connecticut, for example, Statewide Legal Services gives free legal advice and referrals to people with very low income on public benefits problems. Our state pages list legal aid offices where we found them. Vermont’s health care advocate is a project within Vermont Legal Aid, which shows that in some states legal aid and consumer advocacy overlap.

A private lawyer works for a fee that you and the lawyer agree. Fees vary, so we do not quote a price. Ask about the fee before you hire a lawyer.

Triage Cancer, a legal education nonprofit, runs a free navigation program with a team described as trained attorneys. It says the program gives no legal representation. That is an example of useful help that is not a lawyer taking your case.

When a lawyer matters

• A hearing. In Medicaid, the state must tell you in writing about your right to a fair hearing, how to ask for one and your right to be represented. See Medicaid fair hearing: what to expect.
• A lawsuit against an employer plan. Under the Employee Retirement Income Security Act (ERISA), you may sue for benefits due under your plan. The suit may be in federal or state court, and the court may award reasonable attorney’s fees and costs to either side. For ERISA plans, state-law damages claims over a denial are preempted, meaning federal law pushes them aside, so a lawyer should tell you what a realistic remedy is. See suing your health plan.
• A deadline to sue that you cannot see. ERISA sets no deadline for benefit suits, but the plan document may set its own, even one that starts running before your internal appeal ends. Ask for the plan document early.
• A debt lawsuit. If a collector sues you, a legal aid office can tell you what you must do and by when. See medical debt in collections.
• Non-ERISA coverage. For a government plan, a church plan that has not elected ERISA, or a policy you bought yourself, ERISA’s limits on remedies do not apply, and state-law claims may be available. Which ones depends on your state’s law, and we did not check it.

What to do

1. Write down the deadlines you know (your step). Your appeal and external review dates are on your notice. Check the date on your notice, which controls. Do not let a legal search make you miss them.
2. Start with free help. Call the legal aid office for your state and ask whether it handles health coverage, Medicaid or medical debt. Ask what income limit applies.
3. Gather the papers. Bring the denial letter, your plan document if you have it, your appeal and the replies, your bills and a timeline.
4. Ask a lawyer these questions.
   • Have you handled my kind of plan: employer self-funded, employer insured, Medicare or Medicaid?
   • What deadlines apply, including any in the plan document?
   • Who will work on my file, and who do I call?
   • How are you paid, and what costs could I owe?
   • What is a realistic result? I understand you cannot promise one.
5. Keep your internal appeals going. Courts generally require an ERISA claimant to finish the plan’s internal appeals before suing. Ask the lawyer before you skip a step.
6. Put the agreement in writing. Ask for a signed agreement that says what the lawyer will do and what it costs.
7. Name your lawyer as your representative if needed. The plan may need a form. See acting for someone else.

What a lawyer’s office may say, and what to say back

“We do not take health insurance cases.” Can you refer me to a legal aid office or a lawyer who does? What deadlines should I watch in the meantime?

“Your income is over the limit.” Can you tell me where else to look, such as another legal aid office or a lawyer referral service?

The rule

A participant or beneficiary in an ERISA plan may sue “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits.” The court may award reasonable attorney’s fees and costs to either party. See 29 U.S.C. 1132.

Watch for

• Free help is limited. Legal aid offices turn people away for income, case type and capacity. Ask for a referral if they cannot help.
• Information is not advice. Pages like this one cannot tell you what to do in your case.
• Debt and credit rules. These come from federal and state law. A legal aid office and the Consumer Financial Protection Bureau can confirm them. See medical debt and your credit report.

What next

• Paying for an advocate or an artificial intelligence appeal service: the other kinds of paid help and what to ask.
• Suing your health plan: what a lawsuit involves and how it differs by plan.
• Decide whether to pay for help: all the pages on this topic.