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During an annual checkup, my doctor requested blood work to be done, he told me there would be no charge. I later received a bill for the blood work for an amount I never consented to. I was told it was because the health insurance company rejected the claim.

Am I legal required to pay? What would be the consequences if I refuse to pay?

  • You indirectly consented because you signed a piece of paper acknowledging that you are financially responsible for services. They did not force you to have the blood drawn: if you cared that much about the price, you had an opportunity to not have the blood drawn. Doctors are usually not authorized by their employer to make representations about charges and insurance. If you don't pay, they'll send the case to a collection agency. – user6726 May 3 '16 at 18:39
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    @user6726 doctors are often self employed. – phoog May 4 '16 at 5:21
  • You are legally required to pay if there is a judgement against you. If they don't wish to sue you, the only thing on the line is your credit score for a few years. – user2497 Jul 4 '16 at 13:40
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    @user6726 "if you cared that much about the price, you had an opportunity to not have the blood drawn": unfortunately, the chance that a patient in the US will know the cost of any medical service before agreeing to the service is very low. – phoog Jul 11 '16 at 16:19
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You probably don't have any legal recourse.

I once got out of a dental bill by arguing along these lines: "you told me the cost would be X and you knew the terms of my insurance coverage when you provided that estimate, or at least you claimed you did, and I would not have consented had I known the cost would be Y instead of X. "In that case, however, the service was partially paid by the insurer; it was just less of a payment than the office has expected.

Another option you have is to challenge the insurance company's denial of the claim. They may have denied it incorrectly. Look up the diagnosis codes and service codes on your bill and make sure they describe the visit accurately. Read your policy to see the terms of your coverage.

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It may depend on what you can prove and what your jurisdiction is. If you were in New Zealand (we have reasonably strong consumer protection laws), and you could prove (on the balance of probability) that your doctor said there would be no cost - then he would be liable.

Another question would be "Who billed you, and who did you contract to". If, for example, you contracted to the doctor, and all communications were between you and the doctor, but you got a bill from a third party (ie testing company), then they would have to prove you had a contract with them - which you probably didn't.

I'm not sure you don't have "legal recourse". You would not typically take a claim (although in some jurisdictions you can), but you should put your dispute in writing. If the other party don't accept it, they would make a claim and you would defend it (Its probably cheaper and easier that way, and fits better with the way the law is structured). THE IMPORTANT THING IS TO DISPUTE THE CHARGES - otherwise you may be seen as accepting them.

Consequences of refusing to pay could be a bad credit record, depending on how you handle the matter, and/or possibly some time in a courtroom/tribunal with additional fees. They may or may not be able to refuse you service in the future (normally they could, but it may be different with the medical practice)

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In this case the doctor assumed that the test would be covered under your insurance and your insurer denied the claim, so the doctor billed you.

You must pay the doctor.

You then have 3 options: (1) you can sue the doctor because he deceived you into thinking the item would be covered; (2) you can sue the insurance company; (3) you can appeal the denial administratively with the insurance company. In cases (1) and (2) you can sue for more than paid because of the time wasted and mental anguish caused by the problem. In case (3) the best outcome would be that the insurance company pays the claim.

The first thing to do would be to find out why it was denied and determine if there is an easy way to appeal the denial. Based on that, you can make your legal plans.

Without knowing the details of the denial it is impossible to make specific legal recommendations.

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I am going to assume you are in the US because you didn't say otherwise. Other rules apply other places.

Before you go down the 'sue' or 'just pay' routes, you have a couple of other options:

  1. Contact the doctors billing manager and ask them to recheck the insurance filing and to refile/appeal the denial on your behalf. Mistakes happen, and some insurance companies seem to deny claims just to see if you're persistent enough to argue about it. The billing folks should be willing to do this and shouldn't demand payment until the refile or appeal goes through.
  2. If the claim is denied again, you can try to fight it yourself. Google "appealing a denied health insurance claim"; there is good, reputable advice from places like healthcare.gov, WSJ, etc.
  3. If the claim is denied again, the doctors office is going to expect to be paid, and you've probably signed something that obligates you to do so. Explain the situation to the billing manager (nicely) and ask to arrange a payment plan that you can sustain. Most doctors are much more interested in something coming in than sending you to collections, so if you can only afford $25/month payment, offer that.

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