Bad Faith or violation of contract?

[mrjinx]

What is the name of your state (only U.S. law)? Florida

I had to have a surgery for a illness that wasn't responding to other therapies. I went to local doctor and she put in to get the surgery approved. The insurance company denied the surgery saying it was mainly cosmetic even though in there medical policies they list the surgery for as approved for my condition. Because of their denial I went to the expert in the country for this condition and surgery. He said I needed the surgery and put in for it. The insurance approved it but they were out of network. I had to have the surgery because my life was suffering and they ended up shorting me $30,000 that I had to pay.

The question had they allowed me to use the first doctor I would not have been stuck with $30,000. They denied that first doctor based on their negligence. What cause of action do I have if any?

I was thinking bad faith, breach of contract, negligence etc.


Thanks

 

[lealea1005]

They denied that first doctor based on their negligence.

No, the denial was based on the specifics of your policy.

 

[cbg]

When you appealed the decision using the appeal procedure listed in the policy itself, what happened?

 

[mrjinx]

No, the denial was based on the specifics of your policy.

The denial was against what there medical policies said they would cover. The medical policies said the surgery is covered for my condition they denied it saying the contrary essentially lying.

 

[mrjinx]

When you appealed the decision using the appeal procedure listed in the policy itself, what happened?

They denied the paying any more on the claim again. The appeal procedure was AFTER the surgery. They do not allow you to appeal before the surgery.

 

[Zigner]

They denied the paying any more on the claim again. The appeal procedure was AFTER the surgery. They do not allow you to appeal before the surgery.

If doc 1 was covered in full (or close to it) but was denied...and doc 2 was not covered in full but was approved...why didn't you take that approval back to doc 1 and have him resubmit?

 

[cbg]

Do you understand what I mean by the appeal process? Do you understand that I am not talking about the initial denial?

 

[mrjinx]

If doc 1 was covered in full (or close to it) but was denied...and doc 2 was not covered in full but was approved...why didn't you take that approval back to doc 1 and have him resubmit?

Because they don't allow that. Once there is a denial on a pre-service that is it.

 

[mrjinx]

Do you understand what I mean by the appeal process? Do you understand that I am not talking about the initial denial?

They paid like something like $2700 after the surgery which left me with like $30,000 or so. I appealed it AFTER the surgery, they said according to the contract that is all they had to pay. Then they came back after the fact and actually said they paid too much (the $2700) and demanded $200 back!!!!

On another (different) claim they only paid $60 of $2500 I appealed it they said on the paper that they had 60 days to get back to me. 60 days went by and I had to call them telling them they messed up and had not reviewed it yet. Violation of contract?

Thanks

 

[Zigner]

Because they don't allow that. Once there is a denial on a pre-service that is it.

Yet, they approved it for a different doc...

 

[mrjinx]

Yet, they approved it for a different doc...

Yes! And coincidentally the one they would have to pay less money on because he's out of network!

 

[ecmst12]

I suspect that you are incorrect that a preauth denial cannot be appealled. Your first doctor just didn't want to go to the trouble.

 

[mrjinx]

I suspect that you are incorrect that a preauth denial cannot be appealled. Your first doctor just didn't want to go to the trouble.

The insurance company themselves said this.