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CalAttorney2
CalAttorney2, Lawyer
Category: Consumer Protection Law
Satisfied Customers: 10244
Experience:  I am a civil litigation attorney representing individuals and businesses.
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I had a claim with Humana services at an out of network

Customer Question

I had a claim with Humana for emergency services at an out of network hospital. At first the claim was denied, I appealed and then the claim was to be paid at the in network rate of my policy "90/10%" plus my in network deductible of $2400. The EOB in march of 1025 showed the hospital bill of $11,992.06, the amount the Humana plan pays as $8600.39 and the amount I pay as 2856.67. The hospital sent me an adjusted bill showing I owed 2054.07, which I paid. I received a notice from a collection agency that I owed the hospital $8263.83. I contacted Humana claims and the gave me some double talk saying I was now responsible for the $8263.83. Since the EOB they sent me shows they originally agreed to pay the bill per my in network policy rate of 90/10 do I have legal recourse against Humana?
Submitted: 11 months ago.
Category: Consumer Protection Law
Expert:  CalAttorney2 replied 11 months ago.

Dear Customer,

I am sorry to learn of this.

This appears to be a case of "bad faith" (this is a specific form of breach of contract that deals with insurance carriers).

However, with health insurance companies, it is usually best to start with the State Dept. of Insurance and file a complaint (a lot simpler, free to you, and usually faster), you can do so here: http://www.myfloridacfo.com/division/consumers/needourhelp.htm

Make sure to contact the hospital and let them know that you are following up on this so that they do not send the bill to collections (they should not do so while you are dealing with the problem), try to get them to confirm this in writing, and send your own (very brief) letter notifying them of this.

Customer: replied 11 months ago.
I already know about reporting to government agencies, so this info doesn't really help me. I am more interested in the viability of a lawsuit and a list of past lawsuits against insurance companies that were successful in this area of breach of contract.
Expert:  CalAttorney2 replied 11 months ago.

This isn't reporting, the State helps to assist in settling your claim with the insurance carrier.

But as I noted above, this is a "bad faith" claim (which again is a type of breach of contract action). These claims fall within a very small specialty of civil litigation so there are not a lot of attorneys that handle them, but you can find them, most will handle viable claims on a contingency, so you can contact one or more law firms, have them look at your specific documentation (they would actually have to review your case - this cannot be done on a "chat forum") and depending on the merits they may accept your case on contingency.

The "contingency fee agreement" where the law firm will advance its services and the costs of litigation, in exchange for a portion of the client's recovery. So the client will get representation without having to pay anything up front, but will have to reimburse the law firm for its expenses, then pay the law firm a portion of their recovery to compensate them for their time and efforts. (These fee agreements can be changed between the parties, and some lawyers will have the client pay for the litigation costs as the matter is being litigated, and the client will only have to split part of their recovery to pay for the attorney's time when they win).

It is important to discuss with your attorney the details of your compensation agreement at the time that you sign up for services (this contract is usually referred to as the "Legal Services Agreement"), and if you have any questions, the lawyer should be more than willing to explain and discuss them with you.

You can find local attorneys using the State and local Bar Association directories, or private directories such as www.AVVO.com; www.FindLaw.com; or www.Martindale.com (I personally find www.AVVO.com to be the most user friendly).