Retroactively Applying Paid Out Benefits Towards Deductible

[NSLV]

What is the name of your state (only U.S. law)? New York

I receive allergy shots on a weekly basis and see an Allergist who my new insurance, which started in January, listed on their website as a provider. I went to see to Allergist, and the office told me they didn't think they took the insurance, but the insurance paid for the claim, and all subsequent claims from January through March 30, when I received a notice from the Allergist that they had denied my claim saying the doctor was out-of-network and applied the claim to my deductible.

After several frustrating calls with the insurance company, who claimed they had no record of ever paying the Allergist, they informed me that my Allergist was not, in fact, in-network (and was no longer listed on their website) and that this was all leading to the point where they would retroactively apply all my claims since January 1 to my out-of-network deductible and that I may be responsible for all the money they had paid my Allergist for the past 6 months.

So basically, they messed up for 3 months by paying for my allergist, then realized their mistake, and now may take back the money they paid and make me responsible for their mistake. Can they legally do this??

[ecmst12]

They sure can. You don't get to benefit from their mistake, it's called unjust enrichment. They are allowed to correct their mistake and this is money you should have been responsible to pay all along.

[NSLV]

Even though I was under the impression that it was being covered? I even have statements from the insurance company saying it was being covered.

[justalayman]

I tend to agree with you NLSV as long as you have a commitment from the insurance company stating that this provider was "in network". As such, rather than unjust enrichment, I would look to promissory estoppel to defend yourself. You took an action based upon their statements. Their statements were inaccurate so you should not be injured due to their mistake.

[url=http://definitions.uslegal.com/p/promissory-estoppel/]Promissory Estoppel Law & Legal Definition[/url]

Now, the thing is, the doctors office is not a party to this dispute so you do owe them but the insurance company, I believe, owes you for whatever the difference between what you would have paid if this was as they told you and what you will eventually be required to pay.

[ecmst12]

I don't think OP ever confirmed with the insurance company that the doc was in network before receiving treatment from them under this plan.

[You Are Guilty]

Originally Posted by justalayman

Now, the thing is, the doctors office is not a party to this dispute so you do owe them but the insurance company, I believe, owes you for whatever the difference between what you would have paid if this was as they told you and what you will eventually be required to pay.

Detrimental reliance is the term you'll want OP. As long as you can prove that your allergist was listed as an in-network provider during your treatment period, I think you have a strong argument.

On the other hand, without that proof, you're going to have an uphill battle. (In which case you may want to try going up the appeals chain with your insurance company.)

[justalayman]

Originally Posted by You Are Guilty

Detrimental reliance is the term you'll want OP. As long as you can prove that your allergist was listed as an in-network provider during your treatment period, I think you have a strong argument.

On the other hand, without that proof, you're going to have an uphill battle. (In which case you may want to try going up the appeals chain with your insurance company.)

isn't detrimental reliance one element of promissory estoppel?

ecmst12 I don't think OP ever confirmed with the insurance company that the doc was in network before receiving treatment from them under this plan.

I did not understand if OP had proof or not. That is why I stated it as:

I tend to agree with you NLSV as long as you have a commitment from the insurance company stating that this provider was "in network

although OP did state this:

Allergist who my new insurance, which started in January, listed on their website as a provider.

although, is since removed, will be difficult to prove.

along with that, apparently the EOB's were developed with the allergist being considered as; in network, which would tend to support the original inclusion of the provider as in network in the website.

I would suggest that a search on their website would be considered confirmation and although that may have changed since then, the actions of the insurance company of treating the provider as being in network concerning the billings, would support the initial confirmation. While speaking directly with a person (whose name would honestly never be remembered so limiting the value of the phone conversation) would be more convincing and easier to make a claim for inclusion, I do not believe it is requisite for confirmation.