Can an insurance company drop you after receiving a bill and refusing to pay?

Question

In June of 2018, I had a dental procedure done that ended with a total cost of about $1400.

At the time, I was under my parents dental insurance. The dentist office confirmed my policy and claimed that I would pay 50% of the total cost and they would charge the insurance company the rest.

I ended up paying, in full, as soon as they allowed.

The next month, after the procedure, my insurance company contacted my parents to let them know they are dropping me from the plan. It turns out that I wasn't supposed to be on there since I was out of college at the time (recently graduated). They refused to pay the rest of the cost.

I had absolutely no idea about any of that. Apparently, neither did my parents.

Now, I'm being charged with a bill for $1400, which seems to be double the cost they were supposed to charge the insurance company. The last I heard, the dentist has tried to charge the insurance company several times without success.

Had I been informed before the procedure that my insurance wasn't going to cover it, I would have waited until Jan 2019 so that I could use my new insurance provided by my job.

Question:

• Can the insurance company refuse to pay the bill? I understand why they dropped me from the policy, but the policy was active at the time of the charge.

What is my best option?

1. Should I refuse to acknowledge the debt as mine? Can I claim it's the insurance company's debt?
2. Contact my old insurance company and try to get them to pay up?
3. Negotiate with the dentist office to reduce the bill and just pay it?
4. Simply have them fix the charge so that it's accurate (it should be $700, not $1400, since I already paid half), and pay in full?

Do I have other options?

Answer 1

If you were on your parents policy with the understanding you were a student in college, then yes, they can drop you and refuse to pay. You need to read the terms of the insurance very carefully, somewhere in there it says that the policy is only in effect while you are enrolled as a full time student. You (or your parents) broke this agreement, and the insurance company doesn't have any obligation to pay.

1. Should I refuse to acknowledge the debt as mine? Can I claim it's the insurance company's debt?

No, the debt is yours from the moment of service, the insurance company's job is to cover some of that expense on your behalf. It isn't the insurance company's debt, it is yours.

2. Contact my old insurance company and try to get them to pay up?

Unfortunately you will not be successful at this. You violated the terms of your insurance (not being enrolled in school), the company has no obligation to pay. Your parents may be owed some refund of money for any extra premiums they paid while you were not enrolled, but that would be the extent of the insurance company's obligation.

3. Negotiate with the dentist office to reduce the bill and just pay it?

This is probably the best route to go. Insurance companies often negotiate fixed prices for certain procedures that are different than what they would charge uninsured customers. You can ask your dentist if they have any kind of help for uninsured patients.

4. Simply have them fix the charge so that it's accurate (it should be $700, not $1400, since I already paid half), and pay in full?

If you already paid $700, and $700 was your insurance providers portion, then yes, the bill that the dentist sends to you should be $700, not $1400. Make sure though that the entire bill is $1400 though, not $2100 ($700 your portion, and $1400 insurance).

Answer 2

You contracted for the services so the debt is yours. Even if the insurance company were legally obligated to pay, that does not shift the obligation from you to the insurance company. The dentist sues you for non-payment, you have to sue the insurance company for breach of contract to recover what they owe. You certainly can contact the insurance company and ask them to pay, but you should come up with a good reason why it is in their interest to pay. You can also negotiate with the dentist, who may or may not accept reduced payment in exchange for simply getting paid. Legally speaking, you owe for those services.

The question of how much you owe is a little less open and shut. Frequently, service providers negotiate lower rates with insurance companies so that a service that they would ordinarily charge $2,000 for might be capped at $1,400 and they write off $600, because of that contractual arrangement. But you apparently did not have a valid contractual arrangement with the insurance company, so they are not bound by that clause: they can charge you the regular rate of $2,000. If you paid $700 previously, you would owe $1,300. When a receptionist tells you that "you would pay half", that doesn't constitute contractual condition that no matter what, you only have to pay half the bill. It is contingent on your representations, that you have a valid insurance contract with the insurance company, and typically does not represent a promise, it is information that help you to understand why they want $700 even though you say you have insurance.

The core problem is that you apparently broke the terms of the contract with the insurance company since you were out of college and that apparently was part of the insurance contract. This will be specified in the insurance policy, and I assume that neither you nor your parents read that policy carefully to find that detail. It's technically possible that thee is a defect in the language of that clause whereby they do have to cover you, but that is quite unlikely. Still, it would be educational to read the policy and see what it says.

Answer 3

Had I been informed before the procedure that my insurance wasn't going to cover it, I would have waited until Jan 2019 so that I could use my new insurance provided by my job.

A lot will depend on whether your dentist attempted to validate the insurance before the procedure.

If you or your dentist inquired, using your particular insurance plan, group, and ID and your name, whether the procedure was covered, and the insurance company affirmed that it was, then since you've already said that coverage affected your decision to agree to the procedure, then the doctrine of detrimental reliance may provide you with relief. (You should read more about it, and estoppel.)

This doesn't mean that they owe the money according to the insurance contract. It means that their false statement (affirming the procedure was covered specifically for you) caused you to lose money. Just because the written contract says your coverage has ended does not give them the right to falsely tell you that you are covered. However, there also cannot be a material change in circumstance between the promise and your reliance on it. If you were covered when you asked, and became ineligible between that time and the procedure, then their statement wasn't false and they are off the hook.

If you're thinking of pursuing that argument, you should try to collect whatever evidence exists of the statement you relied on.

If you find evidence that you would be convincing to other people, then you would write to their headquarters asking for relief. If that fails, you would turn to either arbitration or small claims court to try to prove that their mistake is directly responsible for the remaining charges, making them liable (for the portion they had represented that they would pay).

Answer 4

Under the ACA ("Obamacare"), young people can stay on their parents' insurance plan until age 26, regardless of your student status. (Wikipedia with references) Your list of options for what to do seems to assume that your parents' plan has some other requirement that you be in college. If you have not yet turned 26 (i.e. are 25 or younger) you should consider investigating further and raising this objection to the insurance company.

Edit: this does not apply to dental insurance that is purchased as its own plan and paid as separate premiums from health insurance. It seems like that's your situation, so my answer probably does not apply. (reference: Health Plans Online)