What to do if being billed for dental services that insurance should have covered?

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What to do if being billed for dental services that insurance should have covered?

I was laid off in mid-June. My dental insurance terminated 6/30/10. Since I was pre-approved for 2 crowns, I asked the Office Manager at the dentist’s office if there was time to do the work before my insurance ended. In front of me she called the insurance company to address all my questions andconcerns. She then assured me that as long as they started the work prior to 6/30/10 she would be able to bill it so that insurance paid. In good faith, I paid my patient portion up front in June. Now, due to some billing error by the dental office, the insurance claim was denied. The dentist’s office is now demanding full payment$1,376.00. Do I have any recourse?

Asked on November 11, 2010 under General Practice, Hawaii

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 10 years ago | Contributor

First, check out the policy and the requirements for coverage itself--IF the insurer needed to pay based on when the work was done and what the work was, you should be able to get it paid, though it may take a great deal of persistence, including in correcting whatever paperwork problems exist.

Second, if there is a valid reason for the insurer to not pay and that reason is due to an error by your dentist's office, you may have valid grounds for either not having to pay (e.g. due a breach of contract theory; they didn't do their obligations) or possibly counterclaiming against the dentist for the portion of the bill that should have been paid by your insurance (under a negligence theory).

So you first need to understand exactly what happened, what your rights to payment are, and why coverage was denied, to see what recourse you may have. Again, if you should have been covered, you should be able to force it through if you appeal and are persistent enough. And if you should have been covered but the dentist messed up, you might have a claim vs. the dentist (you may need to threaten or actually take legal action).

In the meantime, definitley pay any undisputed portion; e.g., if no matter what, under your plan, you would owe, say, $300 of the $1,376, pay that, with a letter noting that you are paying the undisputed amount while investigating or appealing or disputing (whatever you end up doing) the balance. Since you'd have to pay that amount anyway, paying it upfront will put you in a better position should litigation ensue.


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