Legal Question in Insurance Law in Kentucky

payment responsibility

I had a c-section delivery in August of 2006. The admission to the hospital was preapproved by my insurance carrier in February 2006. The surgery was scheduled in July of 2006 and preapproved. When I arrived on the date and time, my ob-gyn (also doing the surgery) was there and we did the c-section. In December, I received a letter from my insurance company stating that an non-participating assistant surgeon's claim was denied. I never authorized the asst. surgeon. I assumed that I had done everything on the up and up. My ob is participating, the hospital is participating. I assumed that all services performed would be from participating providers. I want to be very clear that I NEVER EVEN KNEW THIS ASSISTANT SURGEON WAS NON PARTICIPATING. I DIDN'T EVEN KNOW THAT THEY REQUIRED AN ASSISTANT SURGEON. Now, I'm being told that I need to pay this bill and jump through all these hoops. What can I do?


Asked on 2/26/07, 12:27 pm

1 Answer from Attorneys
Gregory Napier Troutman & Napier, PLLC

Re: payment responsibility

Unfortunately, this is becoming a new trend in dealing with health insurance companies. They are essentially forcing patients to become expect case managers in order to get the full reimbursement they expect.

First, you can complain through the Dept. of Insurance here http://doi.ppr.ky.gov/kentucky/. I would be surprised if this gets it worked out.

There is a doctrine of reasonable expectations in Kentucky insurance case law. Assuming the above complaint gets nowhere, then you will have to file suit based on that doctrine and other causes of action. Do not wait too long to file suit or seek an attorney because there is a statute of limitations. In fact, your insurance contract probably provides for a shorter limitation than the law does.

I suspect you would also have to sue the hospital but that would be a fact specific determination and I could not give specific information on that without more to go on.

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Answered on 2/26/07, 2:08 pm


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