Consumer Protection Law
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Medical/billing question: In August 2012 I was pre-approved by my insurance company for a medically required breast reduction procedure. In August I had received two approval letters from the insurance company authorizing the surgery and a few days before my surgery the hospital called indicating that they received the insurance companies approval. They told me that since I had met most of my deductibles that my out of pocket expense would be around $300.00 - if that! My surgery was on September 17, 2012 and about 45 days later I received a letter from Rawlings company - third party that Aetna had hired requesting information as to whether or not the surgery was related to an injury. I had responded but I continued to be sent the same form letter. In December and finally in January I had called Rawlings Company, he asked if my surgery was related to an accident and I said no. He said no further action is necessary! I haven't received any further letters but the hospital bill still is not paid and it's April 27th 2013. The hospital bill was est. $18,000.00. After my conversation with Rawlings I had contacted the US Department of Labor and told them of the situation - still nothing is done. I sent an email to US DOL - Washington DC and this time I received a call from a supervisor with the DOL. I provide them with the documenation, the approvals and today I received a letter from a collection agency! Please know that I have notified the hospital all along that I had filed a formal complaint. I have written the hospital a letter, an email and have called them. Question: is there anything legal I can do? I am so frustrated!! Response: I am sorry to hear about your troubles. If you were pre-approved for the surgery, the insurance company must pay the bill because you relied on the pre-approval to go through with the surgery. But for the pre-approval you would not have scheduled the surgery and then incurred what would eventually be a bill for over $18,000.00. So, even if the insurance company later decides that the pre-approval is in error, the insurance company must still pay the bill based on implied contract theory of detrimental reliance. That is, you relied on the pre-approval to your detriment, to proceed with the surgery and subsequently incur the medical bills that you have not incurred but for the pre-approval. Since it has been almost a year that you have dealing with this, you may consider retaining the services of a local consumer Attorney to send a demand letter to the insurance company. If the insurance company fails to act or ignores the letter, then the Attorney would file a lawsuit against the company for failure to pay a properly submitted insurance claim, for unfair and deceptive act and practice. Most consumer Attorneys would not charge an upfront fee to handle the case. This means that they would only get paid if they win the case. Even then, Courts award Attorney fees to prevailing consumers. So, you may not have to pay anything to file the lawsuit against the insurance company. You can use the following sites to find local consumer Attorneys: http://www.naca.net
In the meantime, once you retain the Attorney and/or send the demand letter, you can send the hospital an update to let them know that you are still trying to get your insurance company to pay the bill since the insurance company pre-approved the surgery.
All the best,
Thank you for your help! Really appreciate it! I have another situation that I need guidance on. My boyfriend bought a home in 2006; at the height of the housing market). He purchased a home in the State of Washington (Chehalis) and bought at a high price. He got himself into an option ARM which is an ok loan if you are able to refiance. The rate on the ARM was almost 8% and doing some research it appears that it was too high. Also, due to cut backs at work which resulted in lower income he was only making less than the minimum payment. He does have a second on the house which served as the down payment. I believe it was called an 80/20 loan. The interest on that loan was 10/11% - again way to high. Again because of the work cutbacks we went through the modification process and once finally through (another nightmare) the penalty phase of the option ARM stopped but they rolled in about $20,000.00 in penalties. The house is underwater. The house is worth around $140,000.00/$145,000.00; the total amount due on both loans is $213,000.00 and as a result the loss is around $68,000.00. He is age 62, still working, making the payments which are now around $1400.00 a month (combined) but wants to retire at 67. My question(s) : the interest rate on the option ARM loan and the second seems to be extremely high - can we file a lawsuit for this? He is also an Alaskan Native. Also, is there anything that can be done about the $20,000.00 of penalties that was rolled in? Principal reduction? The servicer for both loans is Chase but the the two loans are owed by two different banks; 1)Wells Fargo; 2) US Bank. If you can provide help/guidance, please respond and if not is there someone else that can help? It is really difficult to find a good attorney and from our perspective we don't want to be filing lawsuits just to be doing it! I think there has been a grave injustice with these mortgages and I feel the banks have gotten away with a lot that is borderline illegal and unethical! Please let me know. Thank you! Kacy
Perfect! Thank you
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