Complaint 6 of 12 in “Errors in Claim Payments”

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  • Insurance Carrier: Aetna
  • State: IL

Consumer Complaint:

Our daughter went to FL w/friends. Daughter needed medical attention for ear infection. Arrived at a medical center on a Saturday. Medical provider (receptionist & attending nurse) assured our daughter, the appt would be sent in as urgent care/ clinic appt not an ER appt. Insurance verified it was sent in as an ER appt & amount of $450.00 was put towards our deductable & we would be billed for that amount. After calling the medical center in FL, they verified that they do not have a code for an urgent care/ clinic appt. Our daughter and friends did what they were supposed to, by verifying the appt as urgent care/clinic & that’s not how it was billed. We don’t feel we should pay anymore than our clinic appt charge of $30.00. We pay our own premium ($600.00) each month & feel our insurance should pick up the total.

Insurance Expert Answer:

What you \"feel\" does not matter. The insurance company relies on its contract and what the medical care provider (the medical center) reported.

The medical center is the one who breached its contract with you (your daughter, actually) -- that it would NOT report the visit as an ER visit but as urgent care. In fact if the care was rendered at an ER, that's the way it is usually reported -- and the women should not have promised otherwise. (It's the way medical centers get higher reimbursement, which offsets the heavy-duty equipment and staffing they generally need when dealing with really serious medical emergencies.)

If it was at a \"doc in the box\" -- typically a private medical office that treats a range of medical \"walk in\" issues, including some minor \"emergencies\" but many more routine things for people who don't want to or can't wait for an appointment -- it would have charged less and not reported it in an ER visit.

I don't know what to advise, other than protesting the matter with the \"medical center.\"

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