What to do if my actual health coverage does not match on-line published coverage which has resultedin less actual coverage?

UPDATED: Oct 6, 2011

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What to do if my actual health coverage does not match on-line published coverage which has resultedin less actual coverage?

I bought health insurance through an e-insurer. On the site it publishes maternity coverage as “$25 co-pay for first 4 office visits, then 20% co-insurance after deductible.” This was stated in an on-line matrix summary used to help inform users. I chose my insurance based on this but in all actual coverage is “20% co-insurance after the deductible”, so my first 4 office visits are not covered as published. Looking at the fine print, I see that this is true. Who is at fault?

Asked on October 6, 2011 under Insurance Law, Washington


SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 11 years ago | Contributor

First, when you say, "looking at the  fine print, I see that this is true," what fine print are you referring to?

If it was dislosed on the matrix summary you used to make your decision to buy the insurance--of the matrix or other materials you viewed prior to purchasing even said anything like "Terms and conditions may vary; check the policy we provide you prior to signing to confirm what your costs will be," then it is likely your "fault"--information was there, prior to your buying insurance, which would have let you know that you might pay more or differently.

On the other hand, if all the materials you were provided to help you decide what and whether to buy firmly stated that your first four visits were just a $25 copay, and information about the true cost was buried in small print somewhere on the policy, that may constitute fraud and give you grounds for recovery; an insurer or other company can't do everything in its power to lead you to believe that the cost is X, while only, in a place and form that a reasonable consumer would not look, state that the true cost is Y.

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