Thank you for giving me the opportunity to assist you. Kindly use CONTINUE or REPLY button to ask for clarification or follow-up questions.
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:
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,