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concerned neighbor | Dental insurance problem - am I liable? |
My dentist advised me that I required two crowns. The office manager advised me that he had contacted my dental insurance company and they had agreed to pay a certain amount and asked me to pay approxinmately 30% co-pay. I agreed to this and the work was completed.
In my belief I fulfilled my part of the verbal contract with the dentist to pay my co-pay.
Some weeks later my insurers claimed they had not authorized porcelain crowns and refused to pay their portion. The dentist now expects me to pay this amount.
I spoke to the insurers and they agreed that they had erroneously authorized the dentist ,and that they should resubmit the bill and it would be paid.
the dentist did this, but the insurer still refuses to pay.
I do not feel that I should be expected to pay this portion, due to a mix-up between the dentist and insurer. I fulfilled my part of the payment, and was not advised that I would have to pay if the insurance did not.
How should I proceed? |
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Lori S
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Unfortunately, you ARE liable for anything not covered by your insurance-even if the dentist's office was quoted a verbal benefit, this is not binding. It is your responsibility to know what coverage you have and what the insurance requires for that benefit to be paid.
Your only out is to contact your insurance company and find out what the appeal process is. You will probably have to submit this in writing.
If in the appeal process, it is determined that the dentist's office did not follow the authorization procedure required by the insurance, you may be able to request that the dentist's office reduce the portion you owe, but they are not required to reduce their charges, and chances are, you have signed something (probably the first time you were seen) that states that you are responsible for payment of services rendered, insured or not. |
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roadrunner426440
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You are ALWAYS liable to pay if your insurer does not
The issue is between you and your insurer NOT between the insurer and dentist
Most insurers have a hot line to arbitrate issues like this - use it. |
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src50
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It is unfortunate, but ultimately you are responsible for the unpaid portion of any bill, regardless of the miscommunication between your dentist and the insurance. Try taking it up directly with the insurance company to see if they will cover it. |
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mzJakes
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Ultimately you're on the hook...however, you may want to consult a lawyer on how to proceed. |
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Ann
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If you signed a waiver/contract/forms that advised "you are ultimately responsible for the services" you are liable and should have to pay. Did you recieve a PREDETERMINATION for the services? This will have been information the doctor would have sent to your insurance before the services were done, that stated they would cover the services and at what percentage. This will be the only leg you have to stand on. If you don't have this --APPEAL.
You have the right to appeal, but first call your insurance company and ask why they didn't consider the claim and if they advise the claim has denied correctly, tell them you want to start an appeals process. |
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bljzzgrl
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So there was no written contract at all? I'm surprised.
When you spoke to the insurance company and they said to re-submit the bill, did you get the person's name who you talked to?
Have you called the insurance company back to see why it was refused the 2nd time?
If there was no contract, either at the time or when you began treatment with the dentist (usually this states that you will cover anything that your insurance does not), then legally I'm not sure if they (the dentist) has a leg to stand on.
But if you did sign the "contract" (usually on the paperwork where you give your insurance information) when you first started treatment with the dentist (before the whole crown situation) then you are liable for the difference.
I would personally try to use the option you should have with your insurance office to "argue" that you did your part (also see if the dentist has an "authorization number" that the insurance gave them for the crowns) and that they need to cover this expense. |
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the d
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I hate to tell you this but you will probably be stuck paying it.
was your insurance cancelled or something???
the fact that "they made an error" doesn't count.
I know how it feels dealing with insurance companies, I almost wonder if i am better off without them, starting next month if i want to have health insurance unless a private insurer covers me it will be 429 per month, bs if you ask me. |
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mbrcatz
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Well, ultimately, the dentist is going to sue you for failure to pay, and he'll win that suit.
If it were me, I'd complain in writing, to the state insurance department - and ask them to make the insurance company honor the authorization, even if it was done in error.
THat's really your only shot. |
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