What can we do if our health insurance provider will not allow my daughter to see an out-of-network doctor?

Get Legal Help Today

 Secured with SHA-256 Encryption

What can we do if our health insurance provider will not allow my daughter to see an out-of-network doctor?

We have been referred by an in-network provider to a pediatric neurosurgeon, who has access to the necessary equipment/facilities that could possibly relieve the continuous fight with epilepsy. The provider states that we have to exhaust their in-network facilities, however they do not offer one with what her PCP states is needed. The provider has not technically denied or issued what would be deemed as an adverse benefit determination. Only that they will not allow us to seek out the treatment with the out-of-network provider. I am continuously being roadblocked by claim personnel with no information for appeal.

Asked on January 20, 2016 under Insurance Law, Michigan

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 5 years ago | Contributor

They can't stop you from seeing the out-of-network provider--you can go to any doctor you want--but you may have to pay the out provider entirely out of pocket. Health insurance is a contract; the insurer only needs to pay or provide coverage in accordance with the terms of that contract. No matter how much you need coverage, they don't have to pay otherwise. But you can get the treatment--as long as you pay.


IMPORTANT NOTICE: The Answer(s) provided above are for general information only. The attorney providing the answer was not serving as the attorney for the person submitting the question or in any attorney-client relationship with such person. Laws may vary from state to state, and sometimes change. Tiny variations in the facts, or a fact not set forth in a question, often can change a legal outcome or an attorney's conclusion. Although AttorneyPages.com has verified the attorney was admitted to practice law in at least one jurisdiction, he or she may not be authorized to practice law in the jurisdiction referred to in the question, nor is he or she necessarily experienced in the area of the law involved. Unlike the information in the Answer(s) above, upon which you should NOT rely, for personal advice you can rely upon we suggest you retain an attorney to represent you.

Get Legal Help Today

Find the right lawyer for your legal issue.

 Secured with SHA-256 Encryption