Advice: coverage was retroactively denied, filed legal appeal, what are my options?

Throwaway account.

TL;DR
Insurance company said I had coverage. Went ahead and successfully refilled a prescription. Insurance company now claims I wasn't covered when the prescription was refilled. I filed a claim and was denied. Filed a legal appeal and have been waiting 2 months for a response. Want to know what options I have to not pay $4800 for the screw up on their end.

Background

I have an autoimmune condition and, up until 2022, was covered by my student health plan at my university. I completed in the Fall of 2022 (September) and, given my condition and the cost of my medication ($4800/month), was looking to switch to a temporary health insurance before starting my new job.

In October and before switching insurance, I called my health insurance company to check whether I was still covered given the somewhat odd timing of my completion. They confirmed that I was (a very solid "yes" from the customer service representative). Taking them at their word, I went ahead and filled my prescription, which worked as usual.

Months later, I began receiving mail stating that I owed my previous health insurance company $4800 for the filled prescription. In April, I filed a claim stating that I did not believe I was responsible for the cost, that I had called and verified my coverage prior to refilling, and that I would like them to cover the cost as they had said they would given that I'm not responsible for the poor communication between the departments managing customer service and benefits + coverage. This claim was denied in May and I was told I could file a legal appeal if I was unsatisfied with the outcome. I then filed a legal appeal in June. After hearing nothing, I followed-up in July. Again, no response, I am now (in August) am writing an email to request an update to my case.

I imagine that the general thrust of my case is not especially unique – call insurance company to check coverage, coverage is confirmed, prescription is filled, insurance company then sends an exorbitant bill and asserts I wasn't covered – and I'm wondering if anyone here can provide some guidance to resolve this. Unfortunately, I do not have a detailed record of the phone call I made or its outcome in writing – only the metadata showing that I called their customer hotline on a specific day.

Question(s)

– Do I have a legal case here? I can expand on any details as needed. It's my view that they are at fault for miscommunicating my coverage and are now asking that I pay for something that they original stated they would cover.

– Is there any relevant regulation stating that they must respond in a timely manner to any claims or legal appeals? It's my understand that some regulation exists, but it's unclear to me whether it's relevant to my case.

– More generally, is there any advice that may help me resolve this without having to pay $4800.

Thanks!

submitted by /u/Puzzled-Engineer-438
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