Can your medical insurance company be sued for failing to pay a valid medical claim in full?

Question

I've been struggling to get my evil medical insurance company to pay all of the maternity fees that we were billed recently. They've basically only payed up to a certain amount ($3500), but not paying the full amount (the remaining $2100).
The bill for the obstetric care was $5600, so they are expecting me to pay a $2100 difference! Note that this doctor WAS in-network, so the service should be paid at 100%.

From the research I've done, it generally costs between $5,000-$8,000 for a normal vaginal delivery. So why they are cutting the funds at $3500 is beyond me.

Since something like childbirth is a normal and medically-necessary procedure, could this insurance company be sued for failing to pay the full amount?
And if so, what type of laywer would I need to look into contacting?

Answer 1

You have several "hoops" to get through, but it sonds like you're on solid ground. Lets take each item as it comes up:

You should read your policy. Some policies pay 100% of in network and a lower percentage (plus a deductable) for out of network. BUT, some ploicies pay only a precentage for in network, such as 80% or 90%, or have a deductable and then have a lower percentage for out of network (such as 60% or 70%) and also a higher deductable. Check what your benefits are and what should be due to you/your doctor.

You state that the OB/GYN that you went to was "in network". Accordingly, if you have a plan that pays 100% of in network care, then there is either a problem as to whether the OB/GYN was actually in netwrok or their office does not realize that your plan is an in network situation whereby their bill is to be completely paid by the health insurance carrier. You should discuss the fact that your doctor is in network with his office staff and find out what their position is regarding the balance due. (If they state that he is not in network, find out if he was at the time you started your pre-natal care. If so, you may have an argument to get the carrier to pay even though he later went out of network.) In addition, the doctor's office may accept significantly less than the $2,100 outstanding. If they accept say $210 (10%) as full payment, it's probably better to pay and move on.

If the doctor insists on full payment and you believe that the carrier should pay, contact the carrier and get the names and titles of anyone you speak to. If you don't get satisfaction, file a complaint with your state's insurance department. Also, you might contact you companies Human resources representative.

If all else fails, try small claims court! Filing fees are usually less than $15 and you can go in and represent yourself. However, make sure you have complete copies of the entire insurance policy all medical bills that you are seeking payment for and either proof of payment or a statement (from the doctor) that the amounts are reasonable and still outstanding.

Suing a medical insurance company for failing to pay medical bills is nothing new. Often people with cancer who need bone marrow transplants are denied this procedure (it usually needs pre-certification) and the patient cannot afford to go ahead and pay and then sue the company. Many health insurers consider bone marrow transplants to be experimental, so they deny the pre-certification. In most cases, the courts have directed the carrier to pay for the procedure, finding that it is not experimental, but the delay often causes the patient too much time and then they are no longer candidates. (I guess the health insurer feels that since it does not have to pay for funeral expenses, what the heck!)

In addition to the options above, try getting in touch with your local TV station consumer reporters. they love "warm and fuzzy" stories about a mom and a newborn being denied their proper health care benefits! Let's expose these sleazy health insurers for what they are!

Answer 2

The insurance company will pay 100% of their allowable, NOT 100% of your doctor bill. Say a doctor charges 100.00, but your insurance deemd that their allowable amount is 56.75. They will pay the 56.75 and you are responsible for your co-pays. The rest has to be written off by the doctor. Look on the EOB's they sent (The paper that says how much they paid.) there should be a column that reads "Pt. Responsibility." That's what you owe.

You can fight them in court, but your chances of winning are slim to none.

Answer 3

Of course you can sue, although the cost of suing may exceed your recovery. You may want to try to get your State insurance board and the hospital and doctor to work with you against the insurer.

There has been considerable publicity lately -- notably in the LA Times -- about insurance companies reneging on individual (not group) policies based on trivial and/or spurious discrepancies and alleged misrepresentations in applications for insurance.

Answer 4

Since we don't even know what happened to generate a claim from an insurance company ( the other person's of your own ), how are we supposed to answer your question accurately?

Answer 5

First contact your HR department for help. Second, contact your states insurance department. They are there to help in these types of disputes. If this does not remedy the problem, contact an attorney.