What are my rights if a dental office misrepresented what would or wouldn’t be covered by my dental insurance?

I’m sure you’ve all heard this story before blissfully ignorant patient asks dental office if they take their insurance, office says yes. Gets routine evaluation, oral cleaning and X-rays, uses dental insurance that covers both in and out of network for 100% – gets back bill for $300. Yes. A routine exam and cleaning for $400. Surprise – firstly, they were out of network, and secondly, upon calling my insurance I was told that sure, they covered 100% of those costs – up to a certain limit/cap.

The accountant at my job says all I can do is plea with the dental office to reduce my charges. Am I really out of options here?

Asked on September 5, 2015 under Business Law, Florida

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 5 years ago | Contributor

It's not quite as black and white as your accountant indicates. There are certain legal doctrines that can prevent someone from knowingly lying about insurance coverage e.g. fraud or which can, even when there is no intentional lie, force someone to honor their representation or statement promissory estoppel. However, while these doctrines may provide grounds to hold the dentist liable and force them to absorb any costs over and above what you would have paid had they been correct, the odds are against you
1 Fraud requires showing that there was a knowing lie, which is probabyly not the case here and, even if it were, can be difficult to prove, since this was most likely a mistake or oversight.
2 Promissory estoppel requires, among other things, that your reliance on the statement be "reasonsable"--but it may not have been reasonable to rely on the dentist instead of checking yourself.
So while you may have legal recourse, it would be difficult or challenging to win. Still, the fact that you have possible legal recourse, plus the option  of fiing a complaint with the dental licensing board, may give you leverage you could threaten in good faith to take legal action and/or file a complaint if they don't reduce the bill or absorb some of the cost. Obviously, this works best if you don't want to use this dentist again and don't care about the relationship with them.


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