Please help: Doctor said insurance company would pay; insurance company refuses now.

[Santhosh]

Hello,

I visited an ENT specialist 3 months ago for:
Difficulty breathing due to growth in nostrils and deviated septum; Continuous drainage at back of throat; Periodic sour throat,infections,blocked nose; Wheezing/whistling

My diagnosis was:
A growth in nose; Deviated nasal septum; Drainage at the back of throat

My insurance policy excludes Treatment where no Injury or Sickness is involved/Elective Surgery. An online copy of my insurance policy is at http://www.sas-mn.com/forms/brochure/M17mo(kc.pdf

Doctor said that, Treatment was 'Required' (not elective), hence insurance company would pay. He said he would forward a letter to insurance company to explain the situation if required. Treatment included ‘septoplasty’, 'turbinatrophy' (removing the growth)

I am now confused. I have to pay $2000 to my doctor, $750 to my anesthetist, $3500 to the hospital. I never anticipated a bill amounting $6250

I am a student with no job (1 more year at school). I can’t afford so much. Even with family support, I can only pay part of the bill

Am I legally doomed to pay the bill? Whom should I approach for help? Can the legal system help me out?

Please help

 

[kat30s]

What state are you in? Did the Dr. call the insurance company to verify your benefits beforehand? If he did you may have recourse. Your Dr. would ned to send the insurance company the quotes he got from the insurance company saying they would cover it.....it's called misrepresentation and it would force the insurance company to pay...did the Dr. send his letter saying that the surgery was necessary? Did you sign any financial agreement with the Dr?

 

[cbg]

Unless your doctor did, as the previous poster suggests, contact the insurance company to confirm that benefits were available, his assurance that the insurance company will pay is not binding on the insurance company!

 

[ALawyer]

Many people want to have "nose jobs" for cosmetic purposes, and these are not paid for. Thus health insurance companies are VERY suspicious of claims that may involve a disguised nose job.

In addition, yours seems to be a type of student coverage - which often provide VERY limited benefits -- rather than the broad benefits provided by many employer provided policies (as you would have under a parent's goup health plan). And some of the student insuarnce companies are not known to be liberal.

If there was a tumor or some other thing that was truly causing a medical problem, I don't understand why they should not pay. DO NOT TAKE NO for an answer. Get some more support information from the doctor and ask the doctor to help you fight this. Contact your state insurance department also.