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socrateaser
socrateaser, Lawyer
Category: Consumer Protection Law
Satisfied Customers: 34385
Experience:  Retired (mostly)
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Hello, I did denture with dentist "A" and Insurance paid

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Hello,

I did denture with dentist "A" and Insurance paid 50% of the job and I paid another 50% with my credit card. However, the job was done really bad and I returned the denture to the dentist "A" and he, instead of returning 50% of payment to my Insurance and 50% on my credit card, returned 100% of the payment to my credit card, thus leaving Insurance claim open. I went to another dentist "B" and he did nice job. Unfortunately, my Insurance declines to cover the job of dentist "B" because I reached some claims limit, which means I have to pay dentist "B" in full for the job which is supposed to be partially covered by Insurance. This doesn't look right.
I called the insurance and they told me that dentist "A" should close the claim first (return 50% back to Insurance) and then Insurance will be able to cover 50% of the treatment from dentist "B". So, I went back to the dentist "A" asking him to take that 50% from my credit card and return it to my Insurance and close the claim. However, he said he wouldn't do that as he already returned all 100% of the payment to my credit card, that it is my problem now and he has no time to work on claim with Insurance.
I need legal help to figure out how to deal with dentist "A" and how to make him take money from my credit card and return this money directly to Insurance and close the claim.
Is there any consumer protection law that states dentist must return money to Insurance and not to the patient?
What should I tell to the dentist "A" if he says: "It's your problem now, I have returned all money to your credit card and I have no time to work with Insurance"?

Thanks!
Submitted: 1 year ago.
Category: Consumer Protection Law
Expert:  socrateaser replied 1 year ago.
Hello,

This answer may not satisfy you, but I am obliged to explain what the law "is" and "is not" -- even though the law may not be to your liking.

Insurance is designed to reimburse the insured (you) for health care services. Typically, the insurer pays the service provider, because it takes the burden off of the insurered, who does not have to pay the service provider up front, and then wait for reimbursement from the insurer.

In your case, the insurer has reimbursed you for the dental services received, because the dentist returned your insurance proceeds to you. The insurer is now relieved of having to pay the amount that it has already paid -- otherwise, you would receive insurance reimbursement in exchange for no services rendered.

You can return your 50% reimbursement to the insurer, who would then be obligated to pay your new claim to Dentist B, but as long as you retain the payment from Dentist A, you are obligated to pay out that 50% to cover your costs. And, since your plan is apparently a 50/50 plan, you are also liable for the other 50% -- which is 100% of the Dentist B claim.

Now, if it turns out that Dentist B's bill is larger than Dentist A's, then you would be entitled to additional reimbursement from the insurer to cover 50% of those additional costs, above the amount that you paid to Dentist A, and which you now have received.

But, for example, if you had a credit card bill that had other charges, and Dentist A's repayment has covered those charges, then you have been relieved of a corresponding debt that you no longer have to pay. From an accounting standpoint, you are no worse off than you would have been had the money been returned to you in cash.

BotXXXXX XXXXXne, you cannot recover from Dentist A, and you are fully responsible to Dentist B for the amount originally paid to Dentist A. If there are additional charges, then you would have a new claim for 50% of those Dentist B charges.

Note: If for some reason the insurer refuses to pay the additional Dentist B charges, then you may be able to sue Dentist A for the wrongfully directed refund, because then you would be able to show an economic injury to you based on Dentist A's actions. But, unless and until the insurer refuses to pay any additional Dentist B charges, you have not suffered any economic injury, and without an "injury in fact," you cannot sue anyone -- because that is the fundamental rule of law -- the plaintiff must suffer an injury to have standing to sue.

I hope that my explanation makes it possible for you to understand and deal effectively with the result of these transaction with the Dentists and the insurer. I wish I could give you an answer that would force Dentist A to return your money to the insurer. But, I can't -- at least not unless and until you can show that you have suffered an economic injury related to Dentist A's actions.

Please let me know if I can clarify or further assist you.

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Customer: replied 1 year ago.

Thanks for the answer. Few comments:


 


>You can return your 50% reimbursement to the insurer, who would then be obligated to pay your new claim to Dentist B


I didn't know actually, that I'm eligible to return that reimbursement to the insurer myself. I thought only service provider must return the reimbursement and close the claim?



>Now, if it turns out that Dentist B's bill is larger than Dentist A's


Yes, that is what happening. Dentist B's bill is twice larger that A's



>then you would be entitled to additional reimbursement from the insurer to cover 50% of those additional costs


This sounds fair. But it looks to me that if the insurer was ready to reimburse for that additional costs from Doctor B, it would already to that. But instead they rejected entire claim. I wonder what could be reason for that.



>If there are additional charges, then you would have a new claim for 50% of those Dentist B charges.


Yes, there are additional charges with Dentist B, but the insurer rejected entire claim due to the first claim with Doctor A is still open. I think I should contact the insurer about that?



Thanks!

Expert:  socrateaser replied 1 year ago.
If I were in your shoes, I would contact the insurer, explain what happened, offer to return the reimbursement for the original claim, and state that you are no longer making any claim for reimbursement from Dentist A, because you received no services.

Hope this helps.

socrateaser, Lawyer
Satisfied Customers: 34385
Experience: Retired (mostly)
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