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My husband and I have health insurance through his job. He…

Customer Question
My husband and I...

My husband and I have health insurance through his job. He needed surgery on his cervical spine, he was losing feeling in his arms and hands. We went to a well know surgeon and hospital in our network, his deductible had been paid for the year. I week before surgery he was contacted ny the insurance company stating that all his expenses would be paid if he went to ine of his employers " facilities of excellence" in Arizona, we live in NJ. He told tehm know he couldn't fly and that he wanted to have the surgery done by the surgeon that he had been seeing, a Rothman Institute surgeon. Insurance told him ok but will cost more money, which he knew there would be out of pocket. The Friday before the surgery he was called and told you have to pay $5500 up front because that is the portion the insurance is not paying. As it turns out that is the exact amount of the out of network deductible. We paid it and had the surgery. Can they do this our surgeon and hospital are in network, he had paid his in network deductable

Lawyer's Assistant: Because employment law varies from place to place, can you tell me what state this is in?

NJ insurance co is Aetna

Lawyer's Assistant: Has anything been filed or reported?

No

Lawyer's Assistant: Anything else you want the lawyer to know before I connect you?

I think that is all

Submitted: 8 months ago.Category: Employment Law
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Answered in 5 minutes by:
12/12/2017
Employment Lawyer: Legal Eagle, Lawyer replied 8 months ago
Legal Eagle
Legal Eagle, Lawyer
Category: Employment Law
Satisfied Customers: 14,320
Experience: Licensed to practice before state and federal court
Verified

Hello! I am a licensed attorney, admitted to practice in state and federal court. I have a nearly 100% satisfaction rating (click here for more info) so all that means is that you can count on me to help today. Because I want to provide you with the most accurate answer possible, do you mind if I take a moment to review your question?

Please keep in mind that our conversation does not include an attorney-client relationship and this is for general information purposes only.

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Employment Lawyer: Legal Eagle, Lawyer replied 8 months ago

Thanks for your patience on this. This appears to be a classic breach of contract because your husband had met his deductible and chose an in-network doctor. A breach of contract just simply means that one party was obligated to perform and they have either have not performed or have said that they will not perform. Typically, the aggrieved party is entitled to be returned to the same position they were in before the breach, including any money that they failed to pay to the doctor's office.. There’s a site that I’ve used in the past where you can find a good template for advising of a breach of contract. It's a bit easier (and cheaper) than going through litigation and I have seen it be effective in the past. If this doesn’t work, sadly, the only other option is to either go through an informal mediation or file a lawsuit in your local court. This website is also pretty cool because you can download the forms right after purchasing. Click here to get started.

What other questions did you have for me today that I can help you out with:-)?

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Customer reply replied 8 months ago
Well now my husband is concerned that he may lose his job if if files anything with the insurance company as it was the employer that wanted him to go to the other facility, on the opposite side of the country. I am just so angry, I understand that they were willing to pay for us to fly across country and put us up, but why should we have to with excellent spinal care facilities and surgeons right here. As for me going to help him with his after care, no one was paying me for being out of work.
Employment Lawyer: Legal Eagle, Lawyer replied 8 months ago

I can certainly understand. It's going to be a very tough decision to make as far as how to move forward. Perhaps a frank discussion with the employer about his needs may be helpful. It is possible that the employer wanted him to get better too and receive great care, even at their expense of flying him across the country, so maybe your husband can use that to his advantage. There's no very easy solution;' however, I do know that if he met his deductible and saw an in-network doctor, he is owed t least some justice.

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Employment Lawyer: Legal Eagle, Lawyer replied 8 months ago

Hello, it’s been awhile since we connected so I wanted to check in with you to see if you had any further before you rated. If you have any other questions or if there is anything else I can assist you with today. Please reply here and let me know.

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