A bad faith claim?

[khoj]

What is the name of your state? New Mexico

I had a treatment with a in-network doctor who also ordered a MRI for me which was medically necessary. I have asked the doctor's office to get a prior authorization. The doctor called my insurer and was told the prior authorization was not necessary. My insurance policy says the doctor is responsible for obtaining the authorization.

The claim for MRI was denied without notifying me. I learned it from the hosiptal's bill. I called the insurance and they told me different reasons for the denial from what I learned from the hospital. I had to call the hospital, the doctor's office and insurance office many times to put the puzzle together. The insurance company considered the hospital as out-of-network and I had no prior knowledge about where and who would render my MRI ordered from the in-network doctor. I had only contracted with the doctor for my treatment. The way insurance company handled my appeal was unprofessional and not fair. I am still in the appeal process.

My questions are (1) is there a law to protect me from being held liable for the bill that was not my resposibility according to the policy, (2) is how the insurance company denied my claim and handled my appeal consitituted bad faith claim, (3) how can the insurance company reasobally expect the patient to get authorization for the facility and other medical providers my doctor used?

Thank you for your input.

[ecmst12]

It is your responsibility to make sure a hospital is in-network before having the test done. The insurance company did nothing wrong. Your doctor did nothing wrong, it's not his job to find out what facilities you are allowed to have testing done at, that's your job. Pre-auth was not required and that is not why the claim was denied so it has nothing to do with that.

What you can do, is call your insurance company's customer service and POLITELY explain the situation. Tell them that you misunderstood your policy and did not realize the facility was out of network. Tell them it was a one-time occurrance and from now on you will make sure to find out if the facility is in network before having any testing or treatment done there. And ASK them if they would be willing to re-consider the claim as a courtesy. Ask to speak to a supervisor if you need to and/or write a letter. They may or may not honor your request, MRI's are very expensive tests and it will be very costly for them to reconsider this claim. Threatening a lawsuit that you have no basis to file will NOT help your case.

If they say no, you can contact the hospital and try to negotiate a lower fee and payment plan with them.