What Is Evidence of Coverage?

If you’ve ever had a health insurance claim denied, the reason may have had something to do with a document called the Evidence of Coverage (EOC). While most people don’t pay much attention to this document when signing up for a health plan, it becomes critically important when a health insurer denies a service, procedure, or device that a patient’s doctor believes is medically necessary. Below we discuss what the EOC is, how insurers use it, and when its misuse may amount to bad faith insurance practices. If you believe your insurance claim has been wrongfully denied, contact Gianelli & Morris to review your situation with an experienced California insurance bad faith lawyer.

What Is the Evidence of Coverage Document?

The Evidence of Coverage is the formal, detailed description of what a health insurance plan covers. It outlines the benefits included in the plan, any exclusions or limitations, and the procedures for obtaining medical services, filing claims, and appealing denials. The EOC is often dozens or even hundreds of pages long and includes legal and technical language that can be difficult for policyholders to interpret on their own.

Despite its complexity, the EOC is a key part of the insurance contract between the policyholder and the insurer. It is supposed to provide transparency, enabling members to understand what their plan includes and excludes. In theory, it helps people make informed decisions about their care and coverage. In practice, however, insurers often rely on the EOC to justify denying services—sometimes without giving the request a fair or thorough evaluation.

How Insurers Use the EOC to Deny Claims

When a patient or provider requests a specific treatment, medical device, or procedure, the insurance company reviews the request to determine whether it is covered under the policy. This review often involves comparing the request against the EOC. If the requested service appears to fall outside the scope of what’s listed—or if it falls into a category of “exclusions”—the insurer may issue a denial.

For example, an insurer might deny coverage for a prosthetic device or a new form of therapy by pointing to a section of the EOC that excludes “experimental or investigational treatments.” In other cases, an insurer may deny coverage for a necessary procedure by citing an EOC clause that says the treatment is only covered under certain conditions the insurer claims haven’t been met.

Sometimes, this process is legitimate. The EOC is, after all, part of the agreement between the insurer and the insured. But there are also many cases where insurers misuse the EOC to avoid paying for care—even when that care is medically necessary and should be covered under state law or the insurance contract itself.

Blanket Denials Without Proper Review May Be Bad Faith

One troubling tactic used by some health insurance companies is issuing blanket denials based solely on a quick reference to the EOC—without considering the specific medical facts of the patient’s condition. This can happen when an insurer rejects a request for coverage without conducting an independent medical review or seeking input from qualified professionals familiar with the patient’s case.

For example, suppose a doctor prescribes a particular type of therapy that is critical to a patient’s recovery, but the insurer simply responds with a form letter stating that the EOC excludes coverage for that therapy—without reviewing the patient’s medical history or considering whether the therapy may fall under a covered benefit as medically necessary. This kind of refusal to engage in a thoughtful review may rise to the level of bad faith. Here’s why.

Under California law, health insurers have a duty to act in good faith when evaluating claims. That means they must give every request fair consideration, conduct a reasonable investigation, and base their decisions on sound medical judgment—not simply rely on generalized exclusions in the EOC. When an insurer shortcuts this process, they may be putting their own financial interests above the health of their policyholders. That’s not right, and insurance companies should know better.

Challenging an Improper Denial

If your insurance company denied coverage for a procedure or service based on the EOC, it’s important to understand your rights. California law gives patients several tools to push back against unfair denials:

• You can request an internal appeal through the insurer.
• You may be entitled to an independent medical review conducted by a neutral third party.
• In some cases, especially when the insurer has acted unreasonably or in bad faith, you may have the right to take legal action.

At Gianelli & Morris, we represent policyholders whose claims have been unreasonably denied by their health insurers. We’ve seen firsthand how companies misuse EOCs to issue blanket denials and avoid paying for medically necessary care. When this happens, we hold them accountable.

Know What to Look For

While it’s not practical to memorize your Evidence of Coverage, it is worth reviewing the document, especially when your insurer denies a claim. Look for key terms such as “medically necessary,” “experimental treatment,” and “exclusions.” Sometimes, a denial based on the EOC is more about the insurer’s interpretation than the actual wording. That’s where experienced insurance lawyers can step in and help.

If you believe your insurer has denied your claim in bad faith by hiding behind a vague or misapplied EOC provision, don’t give up. You may have more rights than you realize—and legal help is available.

Contact Gianelli & Morris for Help With Bad Faith Insurance Claim Denials in California

If your health insurance claim was denied and you suspect your insurer is using the EOC as an excuse to avoid payment, contact Gianelli & Morris for a free consultation. Our legal team has decades of experience standing up to insurance companies that engage in bad faith practices. We’ll evaluate your situation, explain your rights, and fight to get you the coverage you deserve.