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I went to the physician in California, United States. The secretary orally told me that the appointment was covered by my US health insurance, but it was not. Can I refuse to pay on the grounds that the secretary told me I wouldn't have to pay anything?

  • You can try. I managed to get away with this with my dentist, but it was thedifference between full and partial coverage, so they got something even without my payment, and it was also a case where I asked for an estimate before deciding to proceed with the service. Legally, I probably had no case, but they elected to let it go, presumably as a business decision. – phoog Jan 5 '16 at 1:18
  • @phoog If one records the conversation, can it be used as evidence? – Franck Dernoncourt Jan 5 '16 at 1:43
  • Possibly, but I was assuming that the content of the conversation was not in dispute. Legally speaking, the question of what your insurance covers is probably between you and your insurer, in which case even if the doctor gave your incorrect information you should not have relied on it. But pivotallyI could be wrong as I do not know anything about the agreements between your insurer and you or the insurer and your doctor. – phoog Jan 5 '16 at 3:29
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    Double check with the insurance company. I've had a physician visit claim denied because of how the treatment was worded. It was covered in the end. Make sure the dr's office "coded" the visit correctly. – mkennedy Jan 5 '16 at 18:19
  • @mkennedy that is an excellent point. This has also happened to me. I am covered for one audiological exam two years, and as a part of my annual physical I was given a brief hearing screening. This was incorrectly coded as an audiological exam, resulting, the second time, in my being billed $70 for an examination that was supposed to be free. – phoog Jan 5 '16 at 18:49
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You can refuse to pay.

The doctor can either accept your refusal or pursue the debt in court. If he pursues the debt you will probably lose.

The Common Law position

Your contract with the doctor was for him to do whatever he did and you to pay for it. Your contract with your insurer is for you to pay the premium and them to reimburse you for whatever they cover.

The fundamental question is why you were taking the doctor's (via his secretary) advice on your contract with your insurer? The advice was wrong, however, it is difficult to see that there is a case for negligent misstatement; you would have difficulty showing there was a duty of care and even if you did showing what damage flowed from it since it is quite likely that you would have had the procedure notwithstanding the absence of cover, unless it was purely cosmetic.

The Consumer Law position

California probably has consumer protection laws regarding misleading and deceptive conduct - I have no idea what they are. If this is so then your doctor's statement was misleading - consequences may flow from this.

  • "The fundamental question is why you were taking the doctor's (via his secretary) advice on your contract with your insurer" -> some health insurance wants the medical provider to call them directly to get a quote, which will then be forwarded to the patient. Legally, I would tend to guess you are right. – Franck Dernoncourt Feb 22 '17 at 2:47
  • As a side note, it also happened to me that I (as a patient) directly called my health insurance, and they told me incorrect reimbursement information. And if the situation wasn't crazy enough, the same health insurance refuses to provide a listing of procedure and diagnosis codes that are covered upon request. Which led me to ask How to be sure a medical appointment will be fully covered by a health insurance in the United States? – Franck Dernoncourt Feb 22 '17 at 2:48
  • As a second side note, some medical providers when they give a quote or ask to pay the co-pay indicates on the receipt that depending on my insurance the patient may have to pay more afterward. – Franck Dernoncourt Feb 22 '17 at 2:56
  • There's only one choice- move to a country with cheaper and better health systems. Fortunately all of the OECD countries have cheaper and better systems then the US. – Dale M Feb 22 '17 at 3:32
  • I am quite familiar with the French health system (~25 years spent in France, 5 years spent in the US). So far on average I found medical care provided in the US to be of higher quality than the medical care provided in France. That being said, the medical care provided in the US is also very far from perfect, and I agree that the US health system is incredibly messed up. Also, the quality of the medical care between countries may depend on the kind of care one needs. – Franck Dernoncourt Feb 22 '17 at 3:54

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