No Fault Denied Claim Hospital Suing me

[WickedChick]

What is the name of your state? NY

I was involved in a Motor Vehicle Accident back in 1999. I had back surgery in Nov. 2003. I received a settlement from the others insurance company. After a year I found out No Fault denied the hospital bill which was $60,000 and stated it was unrelated to the accident. The lawyer at the time stated since they aren't suing you disregard it, its possible they didnt file the possible paperwork in a timely manner. I never heard from the hospital again, untill 2 years ago when there lawyer contacted me demanding payment. I told him this was due to a no fault accident and they should go after no fault. I sent him the paperwork and never heard from him again. Until, 6 months ago when they sent me a judgement that was awarded to them by the court last year in Feb. 2007 They won in default because I didn't show up. (I never received any paperwork to go to court ) I called up the lawyer and told him this and told him why haven't they filed arbitration and that I want to get a lawyer to look into this because I shouldn't owe this money. The lawyers are asking for alot of money and I can't find anyone who will do this case for little money. (I am on disability can't afford $200 an hr) Now the sheriff has sent me a subpoena asking for more information. I heard that I can file an arbitration but I would need a doctor to show up and pay him out of pocket( Cant afford that) otherwise I would lose. Is there anyone who can help me?? I can I get this judgement off my back? Can I file an Order to Vacate judgement and go to court to tell my side of the story. I was also told the hospital can't sue me for that much. They can only sue me for the amount that No Fault would have paid. Is it to late to vacate judgement? Do I have any other alternatives? Anyone who has any ideas please help me. Thank you...

In addition I just found this out from NYS No Fault Insurance Website in FAQ....

My doctor accepted a No-Fault assignment and rendered treatment. My insurer recently issued a denial of claim based on the results of an insurer medical examination. Can the doctor bill me directly?

Ans: No. By accepting an assignment, the health care provider (assignee) entered into a contract with the injured party (assignor). If the insurer denied payment for medical services rendered based on the results of an insurer medical examination (IME), the assignee must pursue a remedy in court or arbitration. A health care provider who accepted an assignment of benefits from a No-Fault patient cannot bill the patient directly if the submitted claim was denied based on an insurer medical examination.
However, an assignment may be revoked by an assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions of conduct of the assignor.

What happens if my claim is denied?
The insurance company reduced the amount of a medical bill to the Workers' Compensation fee schedule charges. Am I responsible to pay my doctor the difference between "fee schedule" and the amount he/she previously billed?

Ans: No. A health care provider is required by Section 5108 of the Insurance Law to bill in accordance with the No-Fault fee schedules. A provider can not balance bill a patient for fees in excess of those contained in the fee schedule.

Does this apply to me? And if so what actions shall I take???

[FlyingRon]

1. You should have protested the no fault denial. While your lawyer may have said ignore the hospital bill, you should have known that you were about to get seriously screwed. Of course the time to protest this is probably long past. You also should have been submitting to your health insurance (and workman's comp if appropriate). Again your inaction has screwed you.

2. You can try to get the default judgment vacated for lack of service or whatever. Of course this is a delaying tactic only. You can argue that they took the assignment, but it looks like the denial of your claim on the "lack of coverage" reason which they appear to have used. You might get the judgment reduced if it is in excess of th statutory limits.

I'm not sure what you're intending to arbitrate.

Frankly you should have made sure you were going to be covered before surgery due to the excessive amount of time between the accident and the date of treatment. You can bet they're going to want some compelling documentation on that.


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[WickedChick]

First I would like to Thank you for your reply. I know my inactions screwed me but my lawyer had stated that if the hospital just sent the one bill, and never bothered me again, its probably because they didn't file the paperwork in a timely fashion. Now, as for the lack of coverage, No one stated that there is lack of coverage. (which I am sure there is because I know no fault covers up to 50,000. But based on the no fault fees then the hospital bill would have been alot less. I believe its only 1/3 from what i have been told. So that would make this bill alot less and possibly there was enough money in my coverage to cover this and if not then at least some of it would have been paid. Now, as for my inactions, I was told that i have 5 years from the date of denial which would be Nov. 2008 to take any actions for arbitration (To protest the denial from insurance company) I don't know if any of this is true. As for the authorization, 2 weeks before surgery I was brought into the hospital, for pre surgical testing and they had stated they needed all my insurance info for authorization prior to surgery. That was given to them. So as far as I knew authorization was given prior to surgery. I found out though a few weeks ago that No fault doesnt give prior authorization from a lawyer I had spoken to for consulation. I just cant afford a lawyer so I am wondering how can I go about this alone? Also, I am not sure if you read what i posted about the No Fault Law, in FAQ. It states ....
My doctor accepted a No-Fault assignment and rendered treatment. My insurer recently issued a denial of claim based on the results of an insurer medical examination. Can the doctor bill me directly?
Ans: No. By accepting an assignment, the health care provider (assignee) entered into a contract with the injured party (assignor). If the insurer denied payment for medical services rendered based on the results of an insurer medical examination (IME), the assignee must pursue a remedy in court or arbitration. A health care provider who accepted an assignment of benefits from a No-Fault patient cannot bill the patient directly if the submitted claim was denied based on an insurer medical examination.
However, an assignment may be revoked by an assignee when benefits are not payable based upon the assignor's lack of coverage and/or violation of a policy condition due to the actions of conduct of the assignor.
Does this apply to me?? And if so what can I do?? Also whats the statue of limitations that I have to Vacate a judgement, is it to late because they already went to the Sheriff?

[FlyingRon]

The lack of coverage refers to the fact that the they are attributing the injury as not being from a covered accident. You can keep reposting those lines from the FAQ, but I read it the first time.