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In NJ MD accepts preapproved payment for procedure from HMO then sends additional bill...

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botski | Student | eNotes Newbie

Posted May 12, 2008 at 2:51 AM via web

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In NJ MD accepts preapproved payment for procedure from HMO then sends additional bill $300.00 to patient after the fact.

MD sues patient 2 plus years later (small claims court $300.00). HMO advised at the time to forward the additional bill to them ( HMO denied further payment is patient liable for cost?).

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prospero | College Teacher | (Level 2) Adjunct Educator

Posted May 12, 2008 at 12:50 PM (Answer #1)

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Patient is probably liable, depending on whether the HMO's denial of further payment was legitimate or not.  If the payment should not have been denied, then the patient may have a claim against the HMO for failure to pay, and could likely also recover all costs of defending against the MD.

However, chances are that the denial of payment was not wrongful.  HMO plans, like insurance policies, are laden with conditions, qualifications, deductible obligations, co-pay obligations, limitations on liability, and so forth.  While the patient may think it is "wrongful" for the HMO to deny payment, chances are that the HMO is complying with the agreement that the patient signed and agreed to.

Health insurance can be incredibly complicated, and the insurance company makes more money by limiting its exposure to liability.  Always read your policies or plans carefully, or get help from an attorney, to determine whether you are being cheated or not.

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