Arethere grounds for a lawsuitif a surgeon’s office failed to send required documents to an insurerwhich resulted in a denial of coverage forthe insured?

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Arethere grounds for a lawsuitif a surgeon’s office failed to send required documents to an insurerwhich resulted in a denial of coverage forthe insured?

I am trying to get approved for bariatric surgery and received a denial on my first appeal. I have reason to believe the surgeon’s office has been negligent in providing the needed documents to the insurance company. I am requesting all documents from the insurer’s file as well as proof from the surgeon’s office as to what they submitted. I only have one more chance for an appeal.

Asked on September 8, 2010 under Malpractice Law, Pennsylvania

Answers:

MD, Member, California Bar / FreeAdvice Contributing Attorney

Answered 10 years ago | Contributor

You may have grounds for some sort of action but that is all dependent on your state's laws of your responsibilities as a patient to ensure that your doctor is covered by your insurance company and the surgery or procedure is covered by your insurance coverage.  Most states require you to also follow the trail and ensure the proper documents are being sent instead of waiting for your doctor to take care of it.  You have a right to see everything in your file.  You have a right to a copy of your file.  If you suspect your doctor isn't giving you everything, contact the medical board and also contact the insurance board and indicate what is going on and hopefully your doctor will do what he needs to do and the insurance board will think twice before they simply deny your claim.  However, if your doctor indicated to you you may be denied for coverage, and he did submit all of the necessary paperwork, it may no longer be an issue for him to follow up on and it may simply mean you might need additional medical opinions to bolster your second claim/appeal.


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