Legal Question in Insurance Law in California

I was self admitted to a drug & alcohol rehab in 2006 after a 9 year history using crystal meth. The treatment facility billed the correct insurance with the wrong identification number. The ins. said they had no record of me the claim was denied. The treatment facility notified me 2 years later of the situation. Ultimately I submitted the claim and it was denied on appeal as "not medically necessary". I still have an appeal to pursue with the CA Dept of Managed Care. Am I still liable for charges at the treatment facility, even though I paid my the portion they asked, and they were negligent with the claim?


Asked on 3/27/10, 9:47 am

2 Answers from Attorneys

It sounds like the claim was not denied due to their negligence, but rather the insurance company's decision that it was not medically necessary treatment. Therefore you do not have any claim back against the facility to offset your debt to them for treatment. So you owe them the money.

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Answered on 4/01/10, 10:01 am
Edward Hoffman Law Offices of Edward A. Hoffman

I agree with Mr. McCormick. To clarify a bit: the facility might be responsible if its delay had caused the denial of your claim. But your claim was denied on its merits, not because it was late. It presumably would have been denied for the same reasons even if it had been timely. The facility thus didn't cause the denial. There is no reason to make it pay for something it didn't cause.

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Answered on 4/01/10, 12:26 pm


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