Legal Question in Insurance Law in California

My wife needed an upper and lower GI procedure. Our doctor who performed the procedure preferred to have us go to an outside Out Patient Clinic based on our insurance coverage. The Outpatient Surgery Center called us to confirm our insurance coverage and we were told by them that everything would be covered 100% except for a portion of the Anesthesiologist billing. We agreed to pay the not covered portion of the Anesthesiologist. My wife had the procedure done in Sept 2009 and in December we got a bill for $7,700.00. We were told that the Surgery Center is not an approved provider of Healthnet. What can we do? We were told by the Surgery Center prior to services that insurance would cover the costs. If the Surgery Center was an approved provider we would not have any out-of-pocket cost. The Surgery Center made a mistake.


Asked on 1/03/10, 7:07 am

1 Answer from Attorneys
Steven Murray Steven W. Murray, APC

I hope you can document the conversations you had with the provider as to date, time, persons with whom you spoke, etc.

Consider sending the insurer's denial to that provider, with a letter, stating that it is up to them to get the insurer's " mistake" rectified.

Remember, sometimes a patient gets a bill from a provider since the insurer has not yet processed it, so leave it to the insurance benefits department of the provider to straighten this out.

If you do get a denial from the insurer, at that point it becomes an adversarial relationship with the provider since you relied on their representations to your detriment.

Good luck.

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Answered on 1/08/10, 3:01 pm


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