Legal Question in Insurance Law in California

Re: Medical professional err'd in billing

Since she did promise to bill the insurance for you then she breached the contract and i do not believe you are liable for the charges but it may require a court fight. i would not pay her but i would assist her in getting anything she still might be able to get from the insurance company.

Ken Koury

Kenneth P. Koury, Esq.

5807 Topanga Cyn Blvd., Suite G-201

Re: Medical Billing Problems

I'll address the easy part first -- this is not a medical malpractice case. Malpractice involves negligence (or intentional misconduct) in the delivery of medical care, not mistakes in the handling of purely administrative matters. Your situation seems to be a straightforward breach of contract case.

If the counsellor said she was going to work with your insurer and accept direct payment from them (and accepting only the co-payment amount from you suggests that she did make such a promise), and assuming that you never stood in the way of her making the appropriate arrangements with the insurer, then this mistake is her problem and not yours. She could have been paid if she had dealt with the insurer in a timely manner, and she can't make you pay for treatment that you never agreed to finance.

But you need to look carefully at your agreement with the counsellor. Many do not bill insurers, but require the patients to pay directly for services rendered; the patients are then required to submit the bills to the insurer and obtain reimbursement.

Others condition their agreements not to bill the patients on being accepted by the insurer. A provider who takes this approach is obligated to use reasonable care to obtain the insurer's approval in a timely manner; failing to do this for two years is probably not going to be considered reasonable.

As I said, the fact that your counsellor accepted your co-payment suggests that she was willing to handle the insurance paperwork herself and obtain her payments from the insurer. I would need to review the facts in more detail before I would be comfortable with this conclusion, however.

It sounds like the counsellor should still be able to collect from the insurer for the services she rendered in the past year (assuming the insurer approves her treatment), and you should cooperate with her in making the necessary arrangements with the insurer.

As to the services she provided before that, you should explain the situation and tell her that you can't afford to make up for what she failed to collect from insurance. If she insists that you are obligated for the balance, get a lawyer.

Better yet, get a lawyer first to at least review your records in more detail. That way, if you actually are obligated for some reason, you will find out without unnecessarily damaging your relationship with the counselor.

Please feel free to contact me if you have more questions.

Edward Hoffman

Law Offices of Edward A. Hoffman

11620 Wilshire Boulevard, #340

Los Angeles, CA 90025

310-575-3540

310-575-6107 (fax)

[email protected].

Edward Hoffman

Law Offices of Edward A. Hoffman

11620 Wilshire Boulevard, #340