tl/dr: My doctor told me some lab work would be fully covered, but the doctor didn't do the work themselves. They sent it off to a 3rd party lab service. Turns out that one particular test wasn't covered by my insurance and it tripled my bill. The insurance company says I don't have to pay for uncovered services in this circumstance. The lab service naturally disagrees. I don't have any agreements with the lab service. Who is right?

So here's the situation:

  1. Visited a new doctor for a "new patient" visit.
  2. Doctor ordered some blood work
  3. I asked if the blood work would be covered by my insurance
  4. Doctor came back and said everything was covered and I owe no money
  5. The blood work was sent to/performed by a 3rd party lab service
  6. A few weeks later I got a letter from my insurance company informing me of a bill that will show up from lab service
  7. There were about a dozen labs ordered total, all of which were a few hundred dollars. However the "negotiated" rate for services covered by the insurance company was on average ~$10
  8. There was one uncovered lab with a cost of $200
  9. The total bill was therefore ~$300 (~$100 total for covered services, $200 for a non-covered service)
  10. The insurance company insists that I am not responsible for uncovered services if I was not told about them before hand (I asked and was told they were covered, so this is definitely the case)
  11. The lab company of course disagrees, and says that according to their policy I must pay full price for uncovered services

As I was discussing this with the lab company one item struck me. A rep said that, "Obviously the insurance company has a different policy than us, but our policy is that you must pay the full amount for uncovered services".

It occurs to me that the use of the world "policy" may be important here. I don't really care what someone's policy says unless I've actually agreed to them in writing. Of course I have signed agreements with my insurance company, and signed agreements with my doctor, but I expect that I don't have any signed agreements with this lab services provider (I'm checking to see if something about this may have been signed while filling out intake paperwork with the doctor).

While I don't object to paying my bills, I get very tired of my inability to figure out what health care will cost beforehand. This is not the first time I've asked about costs before hand only to get a much higher bill later, and my patience for it is low these days. Therefore, presuming I have any legal ground to stand on, I would really like to push back more with the lab service provider and insist that they discount this uncovered test.

Therefore I need to know what laws/regulations may be applicable here, and whether or not this lab services provider can charge me arbitrary prices for uncovered services despite my best attempts to find out the cost of services before hand.

Is their "policy" legally binding? Are there any laws/regulations that influence my responsibility in cases like this?

  • One company's policy can't negate an others, so for example if it is your insurance companies "policy" that you must be informed prior to service or you don't have to pay, that can't negate the labs policy of "you pay for what you buy". The only recourse you may have is against the doctor who informed you it would be covered, not the lab. Either way you should verify yourself what your insurance covers because health insurance is a huge mess (two doctors in one hospital can have different coverages, etc)...
    – Ron Beyer
    Sep 24, 2020 at 20:14
  • @RonBeyer yes but, which companies policy is relevant? Granted, the lab company is the one billing me, but I did not ask for their services directly nor do I have any agreements with them. It seems quite confusing.
    – conman
    Sep 24, 2020 at 21:36
  • The insurance company policy is irrelevant with regards to needing to pay. Are you sure you are getting the bill from the lab directly, or from the doctor/hospital?
    – Ron Beyer
    Sep 24, 2020 at 21:41
  • It can be argued that you didn't enter into a contract with the lab, but your doctor did. And if the doctor had told you that you have to pay yourself and if you had agreed, that would have been a contract that forces you to pay. But since the doctor didn't tell you that, there is no contract between you and the doctor that forces you to pay.
    – gnasher729
    Sep 24, 2020 at 22:43
  • If your insurance company says you're not responsible, then send them the bill you're getting from the lab, with the charge in question highlighted. Since the insurance company told you that you don't have to pay, they now have to communicate with the lab to either get the non-covered charge waived, or to pay it despite it not being covered. Sep 25, 2020 at 20:25


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