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Dwayne B.
Dwayne B., Lawyer
Category: Consumer Protection Law
Satisfied Customers: 33911
Experience:  Practicing for over 20 years and handled many cases and trials for consumers.
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My insurance company assured me that my doctor would be

Customer Question

My insurance company assured me that my doctor would be treated as in network as there was not a doctor on the list within 25 miles that could provide the service. The paid all claime to that point at 100% minus the 45 dollar copay. When it came to the final proceedure, the kicked the claim over to out of network for pricing, as they had no established or negotiated pricing with him. They came back and said the would price or base the MAC (max allowable charge) on the Medicare rate. They are only paying 800 of the 4835.00 claim. Several time I was lead to believe the would pay 100%. The procedure involved customarily is around 6500.00. Can they do this?
Submitted: 1 year ago.
Category: Consumer Protection Law
Expert:  Dwayne B. replied 1 year ago.

Hello and thank you for contacting us. This is Dwayne B. and I’m an expert here and looking forward to assisting you today. If at any point any of my answers aren’t clear please don’t hesitate to ask for clarification. Also, I can only answer the questions you specifically ask and based on the facts that you give so please be sure that you ask the questions you want to ask and provide all necessary facts.

Based on your facts that should be a breach of contract. However, to know for sure you would have to have a local lawyer review the policy. What I'd suggest you do is visit with a lawyer that does Consumer Law, you can find one at, and then if they find that the policy language does not allow them to do that the lawyer can write a demand letter and you can either sue them or report them to the state insurance commission.

Expert:  Dwayne B. replied 1 year ago.

I haven't seen an insurance policy that would allow them to just pay the Medicare rate under these facts though so I suspect you will end up having a claim against the company.