Health Insurance Company Won't Pay Claim

[alexis2005]

Maryland

Please Help Me?

A doctor from the hospital that I delivered my baby at back in Oct. of 2000, just now (June of 2002) submitted a claim to my insurance company for my delivery back in 2000. The insurance company of course denied the claim due to the fact that the claim said the date of service was 11/2/00. They said there was a time limitation on filing claims with them. Now I received a bill from the doctor wanting me to pay it. What are my rights? Should I submit an appeal with the insurance company? Can anyone give me some advice on what I should do?

Thanks.

 

[cbg]

I don't know whether Maryland has a time limit on how long a doctor can submit a bill to you without forfeiting payment. You'll need to get a determination from the state insurance commission on that.

If there isn't, then you are going to have to pay the bill. You can try appealing through the insurance company but if it is in the plan document that there is a time limit, and it probably is, it's extremely unlikely that you will win the appeal. The bottom line is, you are responsible for seeing that your medical bills are paid.

 

[bowler87]

Many states have law or regulation that will help you overcome the "time-limit on filing" rejection.

Ask your dept of insurance.
Unless the company can show that it will suffer a great deal of harm, this time-limit reject is not legit.

There is no basis for the clause anyway. Goes back to 1920's when companies tried to avoid calims by changing addresses every 4 weeks and then saying they never got the claim!

 

[CIAA]

Alexis, we are not attorneys and don't give legal advice. However based on decades of claims management experience throughout the country, I would say that the answer depends on a couple of things:

First, is your coverage employer group coverge? If so, it is in all likelyhood probably regulated by ERISA labor regulations and the coverage is generally exempt from state laws and common law. In this case, you absolutely need to talk to the plan administrator and follow all the administrative appeals processes which can be very time consuming and cumbersome. It may be that since the plan is subject to administrative law the company can enforce the letter of the contract, but cases like this usually find a friend in the appeals latter if you persist.If previous OB Gyn visits were filed and paid and the delivery pre-certified, try arguing that these facts shoud be regarded as notice of claim.

If your contract is not employer group, then it is likely subject to state law, including state insurance laws.State insurance laws do not forbid time limits and in fact this language is specifically allowed by insurance laws. However,insurance court cases across the country( I'm sure MD is no different)have universally held that to enforce the claim notice time limit the insurer must be able to prove that because of the lapse in time the payment of benefits would be prejudiced; that is, mere guess work (ie, hospital burned and all records destroyed; doctor dead or retired and no records available).

Finally, on more of a pure legal note and, FOR SOME VISITING OR PARTICIPATING ATTORNEYS, here is my question1)a doctor provides goods and services (2)it seems that the patient could reasonably expect that the services include filing your claim, especially if he has taken a benefit assignment....so, couldn't a patient claim a violation of the state's consumer fair trades practices act for not timely filing the claim and then asking you to pay??? If not, why not?

P.S. CIAA is particularly partial to mother's and their children !