What are my rights with my insurance company?

October 23, 2009 12:02 PM

What are my rights with my insurance company?

You are not my lawyer, but...

I am not looking for a legal opinion, but I'd like to find out what my rights are in a situation, and I don't know how. I have insurance coverage through my job with a major national insurer. I had to go for a long-term residential stay in the hospital to take care of some health problems. I knew that it was going to be expensive before going in, so I contacted my insurance company to make sure that the treatment was covered and at what rate it was covered. I was told that yes, the treatment was covered, and it was covered at 70% until my out-of-pocket max of $3000/year was reached.

So, after going through the treatment and getting my bill, I saw that it was covered as it should have been, except that when my out-of-pocket max was reached nothing different happened - I wasn't cut off at $3000 responsibility. I contacted my insurance co and was told that I must have been told the wrong thing before going in, and the type of treatment I underwent had no out of pocket max restrictions - ie I was responsible for 30% of the total cost, which works out to be about 35%.

I've had problems with insurance companies in the past, so I made sure to get written confirmation of my responsibility before going in for treatment. I have two email from customer service saying that my liability was capped at $3000, for the specific treatment I went for. I went through the appeals process with my insurance company and showed them these emails, and my appeals were denied, with no explanation except "sorry, you were told the wrong thing". I am currently appealing through my state insurance commission but I've heard things move very, very slowly.

My question is, what are my rights in this situation, legally? It seems pretty straightforward - the insurance company told me a treatment was covered, and then after I had it done they changed their tune and won't cover it. So they should be forced to pay for what they said they would. But I don't know how the law really works - perhaps insurance companies are allowed to lie to you (maybe customer service communications aren't legally binding), all that matters is the text of the policy itself? It turns out that the policy itself does not have a out of pocket max for this kind of treatment - this is written in the fine print of the 100+ page policy book, which I didn't have at the time of my treatment. All I had access to was a condensed policy booklet that did not mention this exclusion.

Can anyone comment on what my actual rights are in this situation, if any?

posted by btkuhn to law & government (6 comments total)

You need a lawyer.
posted by grouse at 12:29 PM on October 23 [2 favorites]

Anything customer service tells you, vis-a-vis your coverage, is not official. The only "official" determination of coverage is the result of the claims adjudication process, the results of which can be wildly different than what you might be told by customer service. Note, too, that the official determination comes after you've had your procedure. You sometimes get lucky and the customer service opinion and the adjudication results match. Other times, not so much. I am utterly amazed customer service actually sent you email, though. They tend not to want to put anything in writing for exactly these reasons.

One thing to consider, too, is to look into what treatment codes were used by the physicians in the billing. I have found that, sometimes, a slight adjustment in coding can make a difference in the adjudicated coverage. YMMV.
posted by Thorzdad at 12:33 PM on October 23

I have zero expertise in this area, but I would not be so fast to give up on the theory that, since you have were told by an employee of the insurer that you'd have a certain coverage, you should be entitled to that coverage, fine-print notwithstanding. Speaking here in very general terms, insurers are bound by the insurance contract, regardless of whether you've read the fine print. But when you have an agent of the insurer making positive representations about coverage, I would say that things get murkier.

Rather than think about your "actual rights", which only exist in a metaphysical sense that isn't going to do you much good, you need to be strategic. You might contact a few lawyers and see if they'd be willing write a letter to the insurer laying out your case. You might suggest to the lawyer that perhaps the insurer should be "estopped" from denying your coverage at this point, and see what he thinks of that theory. It could be that he thinks its a looser, or that he'll charge more than you think it's worth to pursue.
posted by lex mercatoria at 1:47 PM on October 23

You say you are not looking for a legal opinion but want to know what your rights are. That IS a legal opinion. You need a lawyer.
posted by dfriedman at 2:06 PM on October 23 [1 favorite]

Since you will be paying for a decent chunk of your hospital stay, start going through the bills with a fine-toothed comb. Hospital billing errors are rampant. There are services you can pay to review your bills for you, but I'd bet you can find a good range of absurd charges on your bill all on your own. Consumer Reports has a decent article on the subject. Look for duplicate charges, fees for services not rendered, absurd costs ($100 for a bag of normal saline is not unheard of), or charges for one procedure when you received another.
posted by zachlipton at 6:37 PM on October 23

Every state has an attorney general, and every state has insurance regulators. They may be able to assist you at no cost, and they are likely to be knowledgeable. The attorney general's office is also the home of any consumer affairs office your state has. This is why you pay taxes; use them.
posted by theora55 at 7:54 AM on October 24