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Dwayne B.
Dwayne B., Attorney
Category: Legal
Satisfied Customers: 33405
Experience:  Began practicing law in 1992
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Wife was in car accident (her fault / location Los Angeles)

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Wife was in car accident (her fault / location Los Angeles) - 10 months later (due to her doctors advice to let her face completely heal) she got her broken nose fixed. However, the hospital never got pre-authorization for the nose surgery from either my auto co (USAA) nor medical insurer (CIGNA). Later I was told that the hospital called our medical insurance on the day of the surgery and they declined authorization but the surgery had already taken place (at 6am). I now have a hospital bill for $33k for a simple nasal obstruction repair. The original hospital estimate signed by my wife was for $3000. Our surgeon helped us file an appeal and submitted a lengthy detailed explanation affirming that this procedure was of medicinal necessity but CIGNA still said they wouldn't covered it + I'm out of money w/ the auto coverage. Hence, I am being billed $33k.

Do I have any recourse since the hospital didn't get the proper approval beforehand?

JD 1992 :


Hello, and thank you for contacting Just Answer. I am an expert here and I look forward to assisting you today.



JD 1992 :

Unfortunately, no, there wouldn't be any recourse against the hospital.

JD 1992 :

First, if you review the documents you or your wife signed at the hospital then you will see that you agreed to be responsible regardless of what the insurance company does. In addition, the language will also state that the hospital may file on the insurance on your behalf but it is doing so as a courtesy.

JD 1992 :

Second, and this is mingled with the first point there is the fact that you have contractually agreed to pay for the services.

JD 1992 :

Third, there is the equitable concept of quantum meruit, which essentially means that a person deserves to be paid for services performed.

JD 1992 :

You would be much more likely to succeed if you pursued the insurance company for failing to pay pursuant to the terms of their contract with you.

JD 1992 :

The website is showing you are offline so I will exit so I can assist other customers. Please feel free to ask any follow up questions that you have in this thread. However, please do not issue a rating until our interaction is complete and all of your questions have been answered.

Customer:

Re this: You would be much more likely to succeed if you pursued the insurance company for failing to pay pursuant to the terms of their contract with you.

JD 1992 :

Yes?

Customer:

Re this: You would be much more likely to succeed if you pursued the insurance company for failing to pay pursuant to the terms of their contract with you.

JD 1992 :

It looks like the chat function may be having problems so I'm going to change this to a Q and A format.

Customer:

What's the best way to go after my medical insurer - they've declined me once for lack of authorization (which I trusted my doctor to obtain) and then they declined me again saying it wasn't necessary - even after my doctor vehemently disagreed and wrote out a long explanation that Cigna's appeals people rejected. Per Cigna, they told me I could go to the State Appeal board - which I've been told usually sides w/ big insurance. So is that (State appeal) my best and only move?

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