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I live in the state of Montana. I have a charge at my

Hi. I live in the...
Hi. I live in the state of Montana. I have a charge at my doctors office that I was never billed for. My insurance company paid the bill over a year ago. I now go into my doctors office and am told the insurance company did a redetermination and my provider had to return almost $3000.00! I never received notice of this or new determination of an EOB. Like I was telling you I never got a bill or EOB. Right on the spot my provider required me to sign a payment agreement which I did and cannot afford. Is there anything I can do?
JA: Has anything been filed or reported?
Customer: to a collection agency? No
JA: What state is this in? And when did the issue begin?
Customer: I live in Montana. The date of service was July 5 the of 2016. I was told at my monthly visit in late July this year (2017)
JA: Anything else you want the lawyer to know before I connect you?
Customer: I think that's it thank you
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Answered in 3 minutes by:
8/16/2017
Legal Eagle
Legal Eagle, Lawyer
Category: Legal
Satisfied Customers: 5,943
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 so all that means is that you can count on me to help today. This appears to be a classic breach of contract. If the insurance company agreed to pay for the services that were provided and actually paid, then it is a breach of contract against the insurance company to return that payment. 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. This appears to be a violation of the implied covenant (promise) of good faith and fair dealing by not sending you notice that they were planning to do such a thing after they already approved your claim.. Under the Uniform Commercial Code Section 1-304, every contract comes with implied promises from both parties that they are going to be acting fairly toward one another. The failure of one party to act fairly toward the other can result in a breach of contract. 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 (click here). 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.

Before you rate, did you have any questions for me regarding this?

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Customer reply replied 3 months ago
The insurance company is BCBS of IL.
I spoke with a representative and he stated that my first insurance had paid out as much as they could contractually. Now BCBS says that they won't pay anything because my 1st paid more than they would have.

I understand. So, basically the doctor's office was paid more than they were supposed to get, correct?

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Customer reply replied 3 months ago
The 1st paid and the 2nd was to have coordination of benefit. They originally paid the remainder then a year later requested my provider to pay those monies back I never was billed or given a redetermination of the EOB.

And now the provider is demanding payment from you, is that correct?

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Okay, if this is the case then my original theory stands: this is a breach of contract. If it took them One full year to figure out that the payments for inaccurate, then you are suffering damages well after the fact. Of course, without seeing the full details of your policy I would not be able to tell you with 100% certainty whether they are breaching the contract, but ordinarily waiting so long after the fact to them charge you for something that you thought was paid for is a breach. More specifically, this is something called promissory estoppel. What that means is that you detrimental e relied on their promise to pay and now being charged after the fact is a violation of contract principles. Did you have any other questions for me?

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Customer reply replied 3 months ago
What would be my 1st step towards reconciling?

This one is a bit tricky so you may need to get a lawyer involved to help you reconcile this. However, if you do it on your own, my recommendation would be to try to go through the administrative channels of the insurance company, particularly through their dispute resolution center, if available. It is possible that you may need to bring a breach of contract action against the insurance company in a local courthouse, and that oftentimes will get them to settle. Sometimes, they may require that you go through mediation or arbitration as well. So, you could do it like this to help out:

1. Review your policy to see what the time limit is for them to do a redetermination. Also, determine whether the company requires you to go through mediation or arbitration for certain disputes.

2. If they did it within the time frame, then you may have to work informally with them to avoid having to make payment.

3. If it was beyond the time frame, then you can explain that they are breaching the contract.

4. If they were within the time frame, you could still explain that on the basis of promissory estoppel, you detrimentally relied on their promise to pay and the fact that they have reneged on that promise has resulted in a breach of contract.

5. With this as your backdrop, you may be able to help convince them that a lawsuit is not necessary.

6. You may need to file a lawsuit in your local court, with a breach of contract as your option (assuming they do not require arbitration or mediation). If they do require arbitration or mediation, it would be important to go through that process as they will likely pay (remember it depends on the terms of your agreement).

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Customer reply replied 3 months ago
Thank you
I appreciate the help.

The pleasure is all mine! Further up on the you should see a chance to give me a rating. 5-stars are always appreciated, but it is definitely not required! You can also click here in the future to request me individually. Don’t forget, if you haven’t already, you can always sign up for a membership with Just Answer and start asking more questions on the cheap.

Legal Eagle
Legal Eagle, Lawyer
Category: Legal
Satisfied Customers: 5,943
Experience: Licensed to practice before state and federal court
Verified
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