Problems with dentist - Do I have a case?

[G.79]

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

Hello.

-- Description of my situation --

I am European and I moved to the U.S. (specifically to Tucson, AZ) just over a year ago.

My dental insurance company is United Concordia, and my current 12-month benefit period started on February 1st, 2009.

My insurance reimburses a $1200 maximum per benefit period.

During my previous benefit period (from 02/01/08 to 01/31/09) I underwent extensive dental work (mostly crowns). My insurance payments reached the $1200 maximum approximately during the month of December of 2008.

At that point, I explicitly agreed with my dentist and his secretaries (who are also responsible for scheduling the patients' appointments) to halt all scheduled procedures and to restart them and complete the remaining dental work (verbatim) "next year, at the beginning of my next benefit period". I explained my intentions and illustrated their meaning and their nature repeatedly and very clearly.

Then I told the secretary who was helping with me (he employs several) that I was not sure about the exact start date of my next benefit period would start, and I asked her to kindly look it up, and to schedule my next appointment after the beginning of said benefit period.

At this point, she looked at something on her computer, and scheduled me an appointment for a crown (full charge: $880) on January 15th, 2009.

However, unbeknownst to me, that date was still within my PREVIOUS benefit period.

Assuming in good faith that the next benefit period would start before that date, I showed up for the appointment and, after the procedure, I paid my projected co-pay (i.e., 50% of the full charge).

Now I have received a letter from my insurance company stating that the will not pay for this appointment because it took place within my (already maxed-out) previous benefit period. Therefore, I will have to pay the remaining 50% of my crown out of pocket. My dentist has just billed me as well.

-- My questions --

1) Do I have a case?

Legally speaking, whose mistake was that? Who bears the ultimate responsibility for it?

It is my fault for trusting my dental secretary instead of looking up and double-checking those dates personally?

Or was it the secretary (and/or the dentist's) fault for erroneously scheduling me an appointment within the previous benefit period in spite of the fact that I had expressly and explicitly asked them to schedule my next appointment for a crown after the beginning of my following benefit period?

2) If I indeed do have a case, can I sue them in a small case court?

3) If so, should I sue the dentist, the secretary or the dental practice as a whole?

Thank you very much in advance for all you help, your time and your kind attention.

Best regards,

G.

 

[justalayman]

Do I have a case?

no

Legally speaking, whose mistake was that? Who bears the ultimate responsibility for it?

you

It is my fault for trusting my dental secretary instead of looking up and double-checking those dates personally?

yep

Or was it the secretary (and/or the dentist's) fault for erroneously scheduling me an appointment within the previous benefit period in spite of the fact that I had expressly and explicitly asked them to schedule my next appointment for a crown after the beginning of my following benefit period?

nope

 

[Antigone*]

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

Hello.

-- Description of my situation --

I am European and I moved to Tucson, AZ just over a year ago.

My dental insurance company is United Concordia, and my current 12-month benefit period started on February 1st, 2009.

My insurance reimburses a $1200 maximum per benefit period.

During my previous benefit period (from 02/01/08 to 01/31/09) I underwent extensive dental work (mostly crowns). My insurance payments reached the $1200 maximum approximately during the month of December of 2008.

At that point, I explicitly agreed with my dentist and his secretaries (who are also responsible for scheduling the patients' appointments) to halt all scheduled procedures and to restart them and complete the remaining dental work (verbatim) "next year, at the beginning of my next benefit period". I explained my intentions and illustrated their meaning and their nature repeatedly and very clearly.

Then I told the secretary who was helping with me (he employs several) that I was not sure about the exact start date of my next benefit period would start, and I asked her to kindly look it up, and to schedule my next appointment after the beginning of said benefit period.

At this point, she looked at something on her computer, and scheduled me an appointment for a crown (full charge: $880) on January 15th, 2009.

However, unbeknownst to me, that date was still within my PREVIOUS benefit period.

Assuming in good faith that the next benefit period would start before that date, I showed up for the appointment and, after the procedure, I paid my projected co-pay (i.e., 50% of the full charge).

Now I have received a letter from my insurance company stating that the will not pay for this appointment because it took place within my (already maxed-out) previous benefit period. Therefore, I will have to pay the remaining 50% of my crown out of pocket. My dentist has just billed me as well.

-- My questions --

1) Do I have a case?

Legally speaking, whose mistake was that? Who bears the ultimate responsibility for it?

It is my fault for trusting my dental secretary instead of looking up and double-checking those dates personally?

Or was it the secretary (and/or the dentist's) fault for erroneously scheduling me an appointment within the previous benefit period in spite of the fact that I had expressly and explicitly asked them to schedule my next appointment for a crown after the beginning of my following benefit period?

2) If I indeed do have a case, can I sue them in a small case court?

3) If so, should i sue the dentist, the secretary or his practice as a whole?

Thank you very much in advance for all you help, your time and your kind attention.

Best regards,

G.

It is your responsibility to know when your benefit period begins and ends.

Pay your dentist.

 

[G.79]

Pay your dentist.

I would have paid him anyway.

I am not the kind of person who would use such a situation as an excuse not to pay a medical bill.

Had I hade a case, I would have asked for my money back, but I would have paid him first.

Of course, I will never go back again, and I will complete my dental work elsewhere.

 

[G.79]

@justalayman:

Thank you very much for your reply.

I simply find it unjust that, in such cases, people are not held responsible for their mistakes. I am saying that because she accepted to take upon herslef the responsibility for looking up those dates on my behalf, and she agreed to book my apointment after those dates. I may not have a case, but, morally, I am right. Too trusting and naive, perhaps, but right nevertheless.

 

[justalayman]

@justalayman:

Thank you very much for your reply.

I simply find it unjust that, in such cases, people are not held responsible for their mistakes. I am saying that because she accepted to take upon herslef the responsibility for looking up those dates on my behalf, and she agreed to book my apointment after those dates. I may not have a case, but, morally, I am right. Too trusting and naive, perhaps, but right nevertheless.

maybe but what correct access do they have to your account? Heck, I have trouble getting info on my own account sometimes. I would never trust a doctors office as the definitive word.

they attempted to do what you asked. They should have told you that whatever info they may provide is not binding and could be incorrect. In most cases, they do provide such a disclaimer due to situations just like this.

In fact, an insurance company will often tell you what they say is not binding but can only make a determination when there is claim made.

 

[G.79]

@justalayman:

Thank you again for your kind and helpful replies.

Heck, I have trouble getting info on my own account sometimes. I would never trust a doctors office as the definitive word.

Now I will never do such a foolish thing again!

maybe but what correct access do they have to your account?

Good question! When I asked her if she could look it up, she answered, with a smile, "Certainly!"

they attempted to do what you asked.

Well, technically, my first question was whether or not she "could" look it up for me! If you are unable (or not fully able) to do something, then you "can not" do it.

By telling me that you "certainly can" do something, you are (at least morally) taking some measure of responsibility.

EDIT: Actually, now I suddenly remember that I clearly asked her whether it would be possible for her to tell me the starting date! I could not have been any clearer.

If, after looking it up, she had not found the exact date, or if she had any doubts about it, she should have told me so, instead of scheduling an appointment anyway. After all, I had clearly asked her to schedule it after the starting date.

They should have told you that whatever info they may provide is not binding and could be incorrect. In most cases, they do provide such a disclaimer due to situations just like this.

In fact, an insurance company will often tell you what they say is not binding but can only make a determination when there is claim made.

No, unfortunately she did not provide such a disclaimer and, being a foreigner (we don't have private health insurances in my country), I naturally trusted her.

Had she told me that she was not sure, I would have looked it up myself.

Oh, well: I will archive it as one of life's tough learning experiences. You live, you learn - especially abroad.

Maybe the atribution of (moral) blame is 50-50 after all: I was naive and she was careless.

Thank you again,

G. (a travelling fool)

---

EDIT:

Moreover, tha starting date of the 12-month benefit period is the same for all United Concordia patients, so it is neither account-related nor patient-specific, which means that she did not need to have access to my personal account in order to get that information. And my dentist is a United Concordia preferred provider.