Medical Coverage Denial

[RAY_O_]

in 1998 i injured my neck and for my injury i received out of network treatment for roughly 3 months. aside from my co-pays and deductibles my Health insurance covered all treatments. i re-injured my neck again in 2000 and once again i received roughly 3 months of treatment. but according to my doctor's office/treatment center, my Health insurance refuses to cover $3,100.00 due to not being "reasonable and customary allowances". the treatment center claims they have tried to collect this fee on multiple occasions since december of 2000 with no luck. i have just received notice in the mail from the treatment center that since my insurance company refuses to pay and i am fully responsible for the $3,100.00 and that i have 10 days to contact them to arrange payment. when receiving this most recent treatment(year 2000)i recall more than a few times that i qestioned the "staff" as to whether the treatments being administered were covered and was assured that they were. also, why would essentially the same treatment be "reasonable and customary" the first time i received it and not the second time. please advise.

 

[ALawyer]

You are in the middle between the provider and the Plan. Perhaps the truth is also. The conclusory statement of the Plan that it is not reasonable and customary is just that -- a bald conclusion. Make them justify it to you. Was it too many visits or too much per visit.

If in fact the provider's charges are too high, and beyond R&C, tell them that. Unfortunately many providers do charge more than Plans like to pay, and the plan may not have adjusted for the type of injury, severity, re-occurence, etc. Or the Provider may be right in charging more.

I would immediately write to the Plan and tell them that unless they justify it and pay, or otherwise resolve this with the provider, you will have to sue the Plan and the provider.

I would also ask the Provider to justify the fee, and not just assume it is reasonable -- but the collection agency is only out for the money, so deal with the provider, not a collection agency and get them to justify why their fee is fair.