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Personal Injury Pro
Personal Injury Pro, Attorney
Category: Personal Injury Law
Satisfied Customers: 6536
Experience:  Insurance Defense Attorney
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My 19 year old son went to an ED that we verified participated

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My 19 year old son went to an ED that we verified participated in our insurance plan. However, the DDS who consulted with my son was not a participant in our insurance plan. The DDS reviewed my son's CT scan which revealed an nondisplaced facial fx which required no treatment. The DDS spent less than 10 minutes at bedside. He charged my son over
$7,500, of which our insurance says they will only reimburse ~ $ 250.00 (their highest reimbursement level for this CPT).
What would our next action be?
We contacted the insurance company and they told us to send a certified letter to the DDS to ask the fee be adjusted.
We talked to the office manager at the DDS who told us to send a letter to the insurance company to ask that they pay for the service.
Of note, my mother, who I was caring for on hospice took her last breaths I was on the computer and then on the phone with an insurance rep to make sure that my son got to an ED that participated in our insurance plan.
I sure feel like I did as much diligence as I could in assuring my son received care at a covered center.
My son is 19. We got him this insurance purposefully, as we knew he would be living in several states over the next few years and this company has providers in many states.

What are our next steps? My son is a college student with almost no money. Also, we claimed him as a dependent last year. I wonder if the hospital can try to get money from my husband and I from this hospital service which was provided this year.

Personal Injury Pro : Hello!


Personal Injury Pro : The first thing you need to realize is that your insurance company is going to do everything they can not to pay this, but the fact is, if you went to a covered entity and a medical expert was brought in for a consultation who was not covered by your plan, your insurance company will be required to pay. You need to ask for a waiver from your insurance company so that they go ahead and pay this. If they deny it, you can go in front of a judge for a declaratory judgment and/or sue the insurance company for operating in bad faith.

Thank You,




If the insurance company does not pay, would it be helpful for us to retain a lawyer to represent us? How do we make sure we find an appropriate attorney? We are in Oregon. DDS provided service in NY.

Personal Injury Pro : Generally, an insurer may be liable for the tort of “bad faith” whenever it: (i) unreasonably denies an insured’s claim, (ii) fails to conduct a reasonable investigation, (iii) wrongfully refuses to defend an insured sued by a third-party, (iv) fails to provide an adequate defense to an insured sued by a third-party, or (v) fails to settle, without a reasonable basis, a third-party’s suit against an insured.

Initially the insurance company was set to pay the provider the full billed amount.


Then they adjusted their explanation of benefits and reimbursed the DDS at what they call their " highest rate of reimbursement" which was $ 235.00,leaving us to pay the rest. They did fully cover the hospital outpatient charge, the radiologist charge and the CT scan.


Oh, and Thank You so much for your time tonight! Lawyers are amazing!

Personal Injury Pro : Now, as you're fighting with the insurance company, you are also going to want to protect your son's credit against the doctor/provider that this money is owed to. Since he has already been denied coverage from the insurance company, he can go ahead and claim "indigent status" with the DDS to see if they will adjust the price to something affordable or write it off altogether. The DDS cannot hold you or your husband liable for the unpaid bill UNLESS one or both of you signed as guarantors of your sons medical bills. As your son is a student, he may be able to have the DDS reduce the debt or completely eliminate it. If it is reduced and you have to pay the fee to protect your son's credit, you should be able to get reimbursed by the insurance company eventually whether it happens through your appeal or through you having to seek a declaratory judgment.
Personal Injury Pro : If you have any further questions, please just leave them for me and I will answer them as soon as I am able. If not, would you kindly consider a positive service rating for me at this time? It costs you nothing further to do but it is the only way the site will pay me for my time. Thanks!

Oh, I will absolutely give an excellent review. Let me sit and think for a bit if I have other questions. Thanks

Personal Injury Pro : Sure! Sorry for the delay in my responses. I didn't know you were in the chat and I have been on the phone.
Personal Injury Pro : Looking at all your responses to me that did not show up on my screen before...
Personal Injury Pro : If you have to hire an attorney to seek a declaratory judgment or to sue for bad faith, then yes, you would want a NY one.
Personal Injury Pro : You can search for insurance attorneys here:

We did not sign as guarantors. We do have his monthly premiums deducted from our bank account as his was not set up to do so. Is this a problem?


Is there a certain way to notify the DDS office of my son's indigent status? Just a certified letter? Or should my son just call the DDS office and ask them what format to use to claim this.


Think that is all the questions for now. I will wait for your answer and then complete the rating upon leaving the chat. To triple husband and I are not liable if we claim him as a dependent this year, as he is a full time student? The insurance contract is between him and the insurance company. We are not a part of it, except for allowing the company to deduct premiums through my account.


I am also on a joint checking account with him (his campus age checking account) where he keeps all his money. (about $ 700.00)

Personal Injury Pro : no, that's not a problem
Personal Injury Pro : Yes, I would send a certified letter, show a report card from last semester or a tuition bill, show a tax return for your son, if there is one, and ask for them to write off the bill.
Personal Injury Pro : that is correct. You are not liable for any of his medical bills as long as he is an adult and you did not sign as guarantors.
Personal Injury Pro : With regard to the joint checking account, the ONLY way that could affect you is if the DDS did not grant him indigent status and went to court to get a judgment against him. Then they could get a writ to levy any of his back accounts. So technically, they could take the $700 out of any account with his name on it, even if yours is on there too. That still wouldn't affect your credit though.

Thank You So Much.


That gives me a lot to work with. I feel much more grounded now.

Personal Injury Pro : You're most welcome!

You are great!

Personal Injury Pro and other Personal Injury Law Specialists are ready to help you
Customer: replied 4 years ago.

One more question actually.


I am Andrew's custodian in Oregon for at UTMA account that has several thousand dollars in it that I withdraw to pay for qualified college expenses. I think I recall that in Oregon, Andrew has to be 21 in order to access this account. I can take money out without penalty for his education expenses.


I was wondering if the DDS could get at this money.

Hi again :)

Yes, it is subject to garnishment if the child is over 18. You can always spend down this account for any qualified expenses before they get the writ of garnishment. In any case, it is rare that medical providers sue. It does happen, but not as often as creditors for other debts.
Customer: replied 4 years ago.

Thank You again :)