Legal Question in Insurance Law in California

Insurance Benefits

I've been undergoing on-going medical care from a practitioner who agreed to bill my insurance for my weekly treatments. The payments he receives from my insurance approximately double his usual session rate. When I brought this to his attention, he blamed my insurance company saying they have a set fee for the type of service and that he just bills a service code; they determine the amount. But the amount on the invoices is actually five to six times his normal rate. The insurance company then pays only a portion of that. He has received $2,000 dollars from my insurance company for services that would total $1,800 at his normal rate. But he wants me to pay an additional $1,000 for sessions declined by my insurance. Further, he states that after my paying him the $1,000, that should my insurance pay any further sessions, he'll refund my payment for those sessions (meaning he'll keep the higher ins. payment). He disagrees that I should benefit from the amounts he�s collected above his normal rates. Am I legally obligated to pay for the remaining sessions since he has received sufficient funds from my insurance company to cover what I would have been charged if I had made the payments to him directly?


Asked on 11/15/99, 5:09 pm

2 Answers from Attorneys
Steven Murray Steven W. Murray, APC

Re: Insurance Benefits

If you are in a PPO and the practitioner is a member,

the answer is NO - you do not owe him anything.

It appears he is engaging in a less than lawful scheme,

and you also appear to be a victim.

Why did your insurer decline the $1,000 of his

treatments?

Is this person a chiropractor?

Is there any agreement between you two about his looking to your insurer

for payments?

Please contact me if you wish to discuss this,

because it is difficult to answer your inquiry without

knowing the underlying circumstances leading to

this arrangement.

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Answered on 11/17/99, 3:46 pm
John Hayes The John Hayes Law Offices

Re: Insurance Benefits

This medical provider is basically committing insurance fraud. Chargin the insurance more than his normal rate. You do not owe him if his services have been paid for. If you need help disputing his bill or additional information on your rights as a patient. I can be reached at 888-563-8529. The call and consultation are free.

John Hayes, Esq.

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Answered on 11/17/99, 8:07 pm


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