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Law Educator, Esq.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 88666
Experience:  JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
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I have a HMO insurance and they are giving me a hard time about

Resolved Question:

I have a HMO insurance and they are giving me a hard time about making appointments when I need them for my pain management botox shots. Am I able to get help if Kaiser's membership services is unable to help me?
Submitted: 1 year ago.
Category: Legal
Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your question. I look forward to working with you to provide you the information you are seeking.

If you have an insurance plan, this is considered a contract. If the insurance company is denying or delaying treatment without any justification, then this is considered a bad faith breach of contract with you to provide care. If the doctors are not providing you proper appointments because of your insurance company and you send a letter to your insurance plan that their denials are in bad faith and as such you will pursue them for breach of contract in bad faith and see punitive damages for their delaying your care.

However, one thing the insurance company cannot do is force a doctor to see you if they do not have any openings or it is not a botox day. If the doctor is willing to see you early and the insurance company is refusing to allow this, then it would be the fault of the insurer and you have to send them a letter informing them their denial is bad faith and your doctor needs to send a letter informing them that seeing the doctor a week or so early would be medically appropriate. However, if the doctor has no space for you I am afraid that legally you have to wait for the appointment.


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Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 88666
Experience: JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
Law Educator, Esq. and 4 other Legal Specialists are ready to help you
Customer: replied 1 year ago.


Sorry to ask, Is it possible that the HMO does not have proper time allow for procedures for the number of patients that require the help they need.


This is one way to prevent cost to them. The department chair review my case and said the doctor said it is okay for me to wait for treatment that in the pass two years has allowed me to receive treatment a week prior to the ending of my lasts visits. My shots have been given to me prior to the three month mark. Now because I missed making my appointment, they are making a example of their powder we do not have to care for you because it is not a botox day.

Expert:  Law Educator, Esq. replied 1 year ago.
Please do not be sorry to ask any follow up questions, that is what we are here for and how the system works best.

It is entirely possible that they do not have enough staff and appointment times for all of the patients they have. Most facilities are running on very low staff to keep expenses down and profits up and that is how they operate. You need to get your doctor to arrange to see you early, since the HMO generally will listen to the doctor if the doctor says it has to be done early.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 88666
Experience: JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
Law Educator, Esq. and 4 other Legal Specialists are ready to help you
Customer: replied 1 year ago.


My doctor was the one to give me the heads up her hands are tied, that she will not be allowed to make any changes to her schedule. This comes from her bosses. Her schedule is slated for clinical appointments. Last time I asked the appointment desk how many appointments were for botox it was twice a month mornings' only. My question would be can I request facts from membership services to review if patients requesting service does not equal enough appointments are available? Just stating to the HMO that they do not have the availability to offer the specialty services needed.

Expert:  Law Educator, Esq. replied 1 year ago.
Thank you for your response.

While you could ask for the information making clear you do not want any protected HIPAA information only information about the actual number of patients, I am afraid that there are no laws that can force them to give you the information without a court subpoena, which means you would have to get that information by first suing them for breach of contract and prove then that the breach is they refuse to make sufficient services available as promised under contract based on the number of patients they have.
Law Educator, Esq., Attorney
Category: Legal
Satisfied Customers: 88666
Experience: JA Mentor -Attorney Labor/employment, corporate, sports law, admiralty/maritime and civil rights law
Law Educator, Esq. and 4 other Legal Specialists are ready to help you

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