Legal Question in Insurance Law in New York

My insurance company claims doctor not in network

My husband was diagnosed cancer. The Dr we chose, was not part of the network(I have PPO). The Dr assured me that he applied to be part of my ins network but he was not approved yet. He also told me that he will send letter asking for approval early so he can operate on my husband. I made calls to the co to verify the receipt of letter. In my last conversation they told me that he was approved and he can operate in network(I asked this more than once). To my surprise, I received my Explan of Benef, they only pay 60% cause I chose a Dr not in network. I called and told that my Dr was in network, but not in my area. After discussing this with Dr's office I was assured by his secretary the Dr was in network and was approved by the ins co. In my subsequent inquire, I was told my Dr was NOT in network. As you can see, the ins co gave me different info. Today, I got another Expl of Benef saying the hospital was not in network either. In total I owe over $7,000. The co claims that the approval was for Dr to operate as an out-of-network Dr. I do not need approval from my ins co to seek an out of network Dr. We went ahead with this Dr because we were assured by ins co and Dr that this would be a full covered operation.


Asked on 8/26/02, 6:36 pm

1 Answer from Attorneys
David Slater David P. Slater, Esq.

Re: My insurance company claims doctor not in network

You can appeal the denials. If on appeal they still deny your claim you can await a lawsuit by the hospital & doctor and defend based upon what was stated to you or negotiate a partial payment. Good luck.

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Answered on 8/26/02, 9:58 pm


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