I am currently being charged $605 for a procedure my insurance company is denying.

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I am currently being charged $605 for a procedure my insurance company is denying.

In August of 2015 I had knee surgery. The surgery had to be pre-approved by my insurance provider. They approved the surgery. Later I received a bill for $605 after I had met all of my deductibles and out of pocket cost. It was for the computer assistance. My insurance provider said they do not allow this charge and will not pay it. The health care provider is insisting that I pay it. I disputed it over and over. I did not pay it. Now an attorney is trying to collect the fee on the hospitals behalf. My argument is that the surgery would have been denied by the insurance provider had they been informed that it was

computer assisted. Yes I signed an agreement that stated it was computer assisted at the time of surgery but I assumed since it was pre-approved and I was not aware of the computer assist part not being allowed that I should not have to incur the charges. I was under the assumption the surgery would be fully covered by my insurance provider.

Asked on January 5, 2017 under Insurance Law, Wisconsin

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 4 years ago | Contributor

Unfortunately, the law puts the onus on you to ensure that everything is fully covered; you can't necessarily rely on the (admittedly logical) assumption that all charges would be covered if it was approved, especially given that you were aware it was computer-assisted--so you had the knowlege or information necessary to call the insurer and check to make sure it was fully covered. Insureds are responsible for all charges not covered by insurance, so as a general matter, you are liable for this uncovered charge.
You could try fighting it, but given they insurance law works in our county--that assumption that you have to pay all uncovered charges, even if not aware of them ahead of time, plus the fact that you had written acknowledgement that there was computer assistance--the odds are against you; you'd have to show essentially that the charge was fraudulent to have a good charge of prevailing. Couple that with the fact that one or more of the agreements you signed (i.e. with the doctor or provider) very likely provides that if they have to sue you, they can collect legal fees, and fighting is likely a bad idea: low probability of winning, coupled with a high probability of increasing what you owe.


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