Requested preapproval now have to pay

[tchodgd]

Child went to dentist for checkup, dentist requemended she have a pallat widening device put in. (Not critical now but eventually, the sooner the better) Asked the office person to get preapproval prior to making the appointment. Couple of days later got a phone call, appointment was set. Procedure was done. Now I find out from my insurance BC/BS that the procedure is not covered.

When you call BC/BS for preapproval a telephone message tells you to have your health care provider contact us.

Dentists office says they are not responsible for determining whether a procedure is covered and that I am responsible for any procedures done.

They made the mistake, now I have to pay for it?

Do I have a case here?

 

[ALawyer]

This is really a contracts question, not an insurance law question, but here goes.

The dentist did the work. The question is what should you pay for the work done? Nothing (doesn't seem reasonable) or what his standard fees are (perhaps ditto). Yet the work done benefitted you, not the dentist.

One question is who said exactly what to whom, and when? If you clearly told the dentist that you would do the work only if it was covered by the dental insurance and that you would not have the work done otherwise, and the dentist agreed to check, and then told you they did check and falsely told you it was covered (even though the insurer said it wasn't) you'd have a basis to dispute the charges. If they simply didn't check, and you didn't explicitly confirm that it was covered with the dentist, you really have far less of a basis for complaint. If the insurer said it was covered, and then claimed it wasn't, that's something you'd have to complain about with the insurer.

In any event there likely would have been a big co-pay that you'd have had to pay the dentist even if the procedure was covered. I'd say this is something to compromise on and then switch dentists.


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