Question
What is the name of your state? TX
I had a nasal surgery last year, which turned out not to be covered by my health insurance. However, I believe that it is doctor's office that misled me into believing it was covered by my insurance, after I had contacted with the doctor's office to ask about the information that I had obtained from the insurer that the surgery was only to be covered on certain contitions.
I contacted with the insurer two weeks before the scheduled date of the surgery and they told me that the surgery was not covered unless there was a "predetermination" (I can not remember the exact word but); I wrote it down and asked the provider's office about this. Their answer is that they are experienced with this and had already sent a routine letter to the insurer (now I understand that they assume that the insurer would just need some evidence from the provider to demonstrate the medical necessity, which is a routine procedure for this kind of the surgery), and told me not to worry about this.
After the surgery, I recieved the bill from the hospital (later from the provider and anesthesiologist) which made me realize that the surgery was still not covered. I asked the insurer and their answer was that the nasal surgery was excluded from the coverage (which is true as I found out later, the nasal surgery is in the list of the excluded surgeries in their policy). The insurer also told me that they called the provider four days prior to the surgery that the surgery would not be covered. However, the provider's office claimed that they had not received such a call from the insurer.
In the early Feburary this year, the provider's office sent a letter to the insurer and began an appealing process against the denial of the claim that my surgery should be covered on the basis of the medical necessity. However, the appeal was denied.
I understand the it is the patient's responsibility to find out if the surgery would be covered by his own insurance policy. I also understand that the insurer has the right to deny the appeal as the exclusion has already been specifically listed (although it is rare that such surgery is not covered even if it is based on medical necessity).
I understand the responsibility for the provider is perhaps only to provide the medical service. However, I am wondering if the provider's office actually have the legal obligation to provide the correct information or at least not to give the wrong information, when they are asked by the patient , particularly after the patient had contacted with the insurer and the insurer had informed that the surgery was only to be covered on certain contitions. Should the provider be held, at least at some level, for the responsibility for the "mistakes" (or called misinterpretation? my English is not good) involving my case? I guess that the doctor's office was just as surprised as I am that the surgery was not covered. (My health insurance was bought by my school and changed one month prior to the surgery. The provider is actually affiliated with the school and his office is familar with the old insurance policy but certainly not the new one)
Thanks for reading this rather long message. And of course your advice will be greatly apprecated!
Yue
Answer
Sorry, but unless the insurance policy specifically places the burden of coverage responsibility on the provider, they have no responsibility to provide ANY information about your insurance coverage. As you yourself admit, it is your responsibility to know what is in your policy and to determine what is covered.