Ins refusing to pay hospital bill

[pele]

What is the name of your state? NJ

My niece in NJ had impacted wisdom teeth with large cysts which were removed in the hospital four days ago. The cysts were so large that the oral surgeon told her that her jaw might break during surgery due to bone loss and she might need to have her mouth wired shut (luckily this did not happen). One tooth was in her sinus. She originally went to the dentist because her jaw was numb (from the cyst causing pressure on the nerve). An hour before surgery the insurance company called and said they would not cover the hospital costs. Her husband and nurses talked her into having the surgery, which was absolutely necessary due to impingement on the nerve. She checked with the doctors office a month earlier to make sure everything was approved. The lady at the doctor's office said everything was covered. When they called her at the hospital to say it wasn't her husband called the insurance company and they said no one ever called to clear this surgery and it will not be covered in the hospital. She had to stay in the hospital a day longer due to vomitng blood. So I have two questions.

1. Should the dentist's office take some responsibility, especially since they told her everything was approved. They should have had the approval in their hands before they scheduled surgery. I know from working in the medical field that insurance companies often "lose things" and then deny they ever got them (i.e. operative reports stapled to claim forms). Should she get an attorney?

2. Since she had complications from the surgery shouldn't her insurance company pay for that part of the bill? I think she has an HMO.

Thank you in advance for your help. I know you are going to say that she went ahead with the surgery knowing it was not covered, however, the surgery was necessary and should not have been put off because of pressure on the nerve.

Thank you for any input you can give.

[cbg]

Does she have dental insurance? Removal of wisdom teeth are often covered under the dental rather than the medical.

It's a shame that there was some confusion about the coverage but the policy cannot be compelled to cover something that's not included in the coverage because of that confusion.

As to whether the medical insurance should cover the complications, that's doubtful since the main procedure was not a covered benefit, but a definite yes or no will depend on the terms of the policy.

By all means consult with an attorney if it would make you feel better, but I suspect that there's not much that can be done. But check with the dental insurance first, if there is any. It's quite possible that they will be willing to cover the procedure.