What to do regarding perusing a claim against our insurance company?

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What to do regarding perusing a claim against our insurance company?

My husband was diagnosed with cancer about 9 months ago. Then, 3 weeks into treatment, his employer switched health insurance carriers and we had to fill out forms for transition of care because the insurance company was out-of-network. The insurance company agreed to pay as in-network and for the last 8 months, they have been paying the bare minimum of the claims. I have been in contact with the center who treated my husband’s cancer and they have repeatedly re-submitted the claims, only to be paid the same rate again.

Asked on May 17, 2018 under Insurance Law, Delaware

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 2 years ago | Contributor

If the center is out-of-network to this insurer, they do not have to pay other than as out-of-network. They are under no obigation to pay more than that; and if they voluntarily agreed to pay other than more than that, any payment above-and-beyond what the terms of your coverage obligate them to pay is subject to their discretion: they can pay as much or as little over the contractual minimum as they choose (again, assuming they choose to pay more than they are required) and can discontinue same whenever they want. The insurance policy is a contract: if they are not paying what the policy requires, you could sue for breach of contract, but so long as they are paying what the terms of your coverage require, you would not have any claim against them.


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