Is a doctor required to inform patients in advance if procedures they are about to perform aren’t covered by the patient’s insurance?

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Is a doctor required to inform patients in advance if procedures they are about to perform aren’t covered by the patient’s insurance?

My wife went to her doctor for an annual physical. She filled out the insurance form that the doctor gave her and clearly stated that who our health insurance company was. Nobody at the doctor’s office, nor the doctor herself, mentioned to my wife that there was any problem with the insurance. Our insurer provides us with free annual physicals, so this checkup should have been no cost to us. However, weeks later the doctor sent us a bill for $453 saying that they are not associated with our insurer. I believe that the doctor has a legal responsibility to inform patients in advance if services they are going to perform are not covered by the patient’s insurance. Since this was not done, I do not think I have an obligation to pay the $453. Is my viewpoint legally correct?

Asked on January 30, 2012 under Business Law, Texas

Answers:

FreeAdvice Contributing Attorney / FreeAdvice Contributing Attorney

Answered 9 years ago | Contributor

If your wife went to her doctor for an annual physical believing that she was covered for the examination under her health care insurance where she filled out the insurance form before the examination, some person at the doctor's office under acceptable custom and practices should have advised her before the physical began that your health insurance did not cover the costs for the examination.

What would be worse for the doctor is if your wife was an existing patient and the doctor's office recently changed policies to not allow insurance payments and coverage from your health care provider.

I suggest that you have a meeting witch the doctor where any amount your wife would be obligated to pay would be the co-pay amount if applicable.


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