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Law Educator, Esq.
Law Educator, Esq., Attorney
Category: Business Law
Satisfied Customers: 110581
Experience:  All corporate law, including non-profits and charitable fraternal organizations.
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2 years ago on June 18th, 2014 my fiancé and I were in

Customer Question

2 years ago on June 18th, 2014 my fiancé and I were in an accident, a tree fell on our car. The insurance and hospital (hamot) were communicating pretty good. My fiancé got bills in the mail from hamot and called to give her insurance information several times, it's like Hamot lost her information repeatedly. My bills were all taken care of. She received a bill in 8/2014 but we thought everything was taken care of and the insurance covered their share, and she already paid all her costs. The bill was for 1965.00, last year, 2015, we heard nothing from Hamot. This year at the middle of May of 2016 we received a collection agency notice saying she owes $544. She called and confirmed her identity, I talked to the person and he stated that is for Hamot for 1965 and more than likely the insurance won't cover it because it's been so long. She called the insurance company she once had (she doesn't have it anymore since she quit the job that carried her), and they stated in a letter to us :"Thank you for your recent inquiry to Highmark Blue Cross and Blue Shield.Please be advised that any clams that we receive for date of service June 18, 2014, will be denied for timely filing. The time period for submitting a claim is one year from the end of the year following the date of service."My question is, why are we the ones that Hamot wants us to pay, is this even legal? Someone doing the billing at Hamot messed up, not us. How can all the other bills, the emergency room, the MRIs, medicine, etc are paid for? But this bill for the Neck specialist isn't (we both broke our necks). I recently started full time, just paid for a wedding, and paying off a car, live in a crappy trailer, and now this popped up. Can we do anything? We live in Erie County in Pennsylvania and She had Highmark Health insurance and went to UPMC Hamot in Erie, PA.Thanks
Submitted: 3 months ago.
Category: Business Law
Expert:  Law Educator, Esq. replied 3 months ago.

Thank you for your question. I look forward to working with you to provide you the information you are seeking for educational purposes only.

First of all, if the claims were submitted to the insurance company, which you said they were because your bills were paid, then there is negligence either on part of the hospital or insurance company (one or the other) and as such you still would not be liable for the bill. However, since they are pursuing this, you would need to seek to file a suit against BOTH your insurer and also the hospital for breach of contract and negligence, since one of the two would be liable here for the improper filing of the claims or the loss of the claims that were timely filed.

You need to try again and inform the insurance company that the claims were timely filed and get a letter from the hospital saying they did file the claims with the insurer in time. In your letter to the insurance company you inform them you are appealing their denial based on the fact the hospital has filed the claims timely and your claims were paid but your girlfriend's were not and tell the insurer it is not your fault if they lost the claims. If the insurer denies your appeal, then you would have to file suit against both the insurer and hospital for the breach of contract and negligence and seek to get the court to order the insurer to pay or that the hospital is not allowed to collect if they were negligent in filing the claim.

These are your only remaining options here.

Customer: replied 3 months ago.
Ok I understand this, but I have a couple more questions. This bill was never filed to the insurance company for some reason, this is why I believe that hamot dropped the ball, so to speak and didn't file the claim correctly. The other bills that were linked to this accident were filed to the claim to the insurance company, and she went through everything with Hamot. On the State's Attoreny General website there is a Highmark and UPMC complaint form, that I was thinking about filling out and trying to send it in, will this possibly fix this situation? Should we even try to talk to hospital? If we do should we talk to a supervisor billing person? And if we do go to file a suit against them both, how would I do this? Will I need to pay for an attorney?Thanks
Expert:  Law Educator, Esq. replied 3 months ago.

Thank you for your reply.

If the hospital never filed the paperwork they were supposed to file for the claim, then they were negligent for not doing so and for not notifying you in time to file the claim yourself, so they would be liable to you for that. The first step is to complain to a supervisor about the matter and seek to get them to write the bill off and if they refuse, you can file a complaint against them with the attorney general. If those two steps fail, you would have to sue the hospital if it was the hospital in fact that was negligent in filing the claim and you would have to pay the attorney to do so or if the amount is less than $12,000 you can sue in small claims court without an attorney.

Customer: replied 3 months ago.
I called the hospital today and told me statements were sent out 9/2014, 8/2014 and 9/2014. Then it was turned over to the collection agency. He then started that auto insurance should cover the rest, my fiance said no it wouldn't. Firstly she didn't have car insurance, secondly she got told no it wouldn't because the car wasnt moving and the keys weren't in the ignition. If it was, she would have been arrested because of not having car insurance. The rep also arrested that the health insurance basically covered what they are going to cover and we would have to pay the rest. On the bills we have it had charges, payments, pending insurance and patient balance.. the pending balance are all zeros. And previously hamot stated the bills weren't issued to highmark for some reason... so what should do now?
Expert:  Law Educator, Esq. replied 3 months ago.
Thank you for your reply.
Of course they will tell you that. However, if you cannot get to a supervisor and explain she had health insurance and they had that information and improperly filed and as such they were negligent and need to reduce the bill, then your final recourse would be that you have to do as I said above, sue them for negligence and the damages they caused by not properly filing the claims with your insurer and not properly noticing you of there being some problem. I would call them back first and explain to a supervisor that there was no car insurance involved it was a medical insurance claim and they negligently handled the information regarding the claim causing her to lose the right to file it herself in time. You need to try to negotiate it down to what the insurance would have paid and you pay the balance that would not have been covered by insurance. If not you will have to sue them.

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