Legal Question in Insurance Law in California

I am being sued by a Speech Therapist provider for $4600 in small claims court. This provider is a in-network provider with my insurance company (via employer)

My insurance plan states that we are only responsible for $1000 out of pocket to reach our deductible, then everything is covered 100%.United Healthcare states "for in-network coverage, the patient is not responsible for the difference between the amount charged by the physician or health care professional, and the amount allowed by the contract."

My wife signed a form stating we would be responsible for any payments our insurance didnt cover 1 day before the first date of service. They offered "in-home" service, so we selected that option. Well, "in-home" service is an additional fee ($4600) and was not disclosed to us. The provider confirmed to us that they are in-network and we are 100% covered. I found out 8 months after the first date of service, that they have been billing the insurance as "in-office", not "in-home". They called us and told us we owed $2000 (now $4600). When my wife called the office back, they said the owner advised the accounting dept to always bill "in-office" since most insurance companies dont pay "in-home" visits.

So the insurance company had the provider rebill every visit as "in-home". the insurance company paid the same amount to the provider as "in-office", so we are being sued the for difference.

Basically because we signed this form stating we are responsible for any cost the insurance doesnt cover, the provider is trying to make us pay the difference between the contract rate and retail rate. They already accepted all the payments from the insurance company. as a insurance member, I feel that the provider cant sue us because they are under contract from the insurance company, and my insurance plan protects us from any additional fees the provider charges.


Asked on 8/23/09, 1:53 am

1 Answer from Attorneys
Robert F. Cohen Law Office of Robert F. Cohen

You or your wife might want to speak with the insurance carrier and explain what's going on. Providers generally are required by contract with insurance companies to accept whatever the "reasonable" rates are, plus your co-pay.

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Answered on 8/23/09, 2:21 am


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