A
ahmajokester
Guest
What is the name of your state? West Virginia
My Health Insurance Provider failed to pay a portion of my claim last year for an Emergency Room visit. The policy covers 100% of Emergency Room visits after deductible. They failed to pay a portion of the claim, saying that the charges exceeded U&C. The incident occurred about 300 miles from where I live.
Here is the relevant part of the U&C definition in the contract:
"...made to persons having similar medical conditions in the locality of the Policyholder..."
I interpreted (and I think very reasonably so) this to mean in the locality where the incident occurred -- and where I had to receive treatment. The Insurance company, however, is basing U&C on WHERE MY PHYSICAL ADDRESS IS, NOT WHERE THE INCIDENT OCCURRED.
I think this can be interpreted either way.
My question is: Isn't this a "contract of adhesion" and therefore, the courts will rule in my favor since there is ambiguity in the contract? Also, if I have a valid argument (to make them pay) what is my best course of action (file small claims on my own, contact Insurance Commissioner)? Is there a time limit on when I can take action? -- the incident occurred last August and they told me they wouldn't pay in November -- I've been trying to think of what to do since then -- is it too late now?
Thanks so much in advance.
My Health Insurance Provider failed to pay a portion of my claim last year for an Emergency Room visit. The policy covers 100% of Emergency Room visits after deductible. They failed to pay a portion of the claim, saying that the charges exceeded U&C. The incident occurred about 300 miles from where I live.
Here is the relevant part of the U&C definition in the contract:
"...made to persons having similar medical conditions in the locality of the Policyholder..."
I interpreted (and I think very reasonably so) this to mean in the locality where the incident occurred -- and where I had to receive treatment. The Insurance company, however, is basing U&C on WHERE MY PHYSICAL ADDRESS IS, NOT WHERE THE INCIDENT OCCURRED.
I think this can be interpreted either way.
My question is: Isn't this a "contract of adhesion" and therefore, the courts will rule in my favor since there is ambiguity in the contract? Also, if I have a valid argument (to make them pay) what is my best course of action (file small claims on my own, contact Insurance Commissioner)? Is there a time limit on when I can take action? -- the incident occurred last August and they told me they wouldn't pay in November -- I've been trying to think of what to do since then -- is it too late now?
Thanks so much in advance.