Do I have to pay for laser surgery when the insurance coverage was not discussed with me?

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Do I have to pay for laser surgery when the insurance coverage was not discussed with me?

My ENT doctor informed me that I needed the laser nasal surgery. He tole me that my insurance would cover it and I wouldn’t have to pay a penny. After a terrible bout with my allergies, he convinced me to make an appointment for the surgery. After the surgery, I received a bill for over a $1,000 because they said that I hadn’t met my deductible. Why wasn’t I informed about this money? I was told that I didn’t have to pay anything. The office manager told me that even though they didn’t discuss it with me, I still had to pay the doctor. I did not sign informed consent.

Asked on January 18, 2011 under General Practice, Texas

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 10 years ago | Contributor

Normally, whether or not the insurance pays, the patient is obigated for the cost. In this case, IF you could show that the doctor/doctor's office misrepresented your insurance coverage to you; that they did so deliberately; and that you reasonably relied on this misrepresentation in deciding to undergo the procedure, then you may have grounds to avoid paying on the basis of fraud. However, that is an uphill battle to fight, especially if you don't have anything in writing from them stating that you were or would be covered. Also, you did get the surgury done, which arguably means that if you don't pay anything, you would be "unjustly enriched" (getting something for nothing), which the courts do not like and often do something about. In this situation, the best reasonable outcome might be to try to settle with the doctor for some lesser amount, on the grounds that you were told you had coverage and would not have done the surgery if you'd known otherwise; therefore, unless you can work something out with the doctor, you will file a complaint with the state board regulating doctors.


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