Legal Question in Insurance Law in New York

Re: Overpayment refund request

Regardless of fault for the error, a claim for unjust enrichment attaches to any overpayment; that is, the person receiving the overpayment was unjustly enriched by it (ie. they received more than they were entitled to under the agreement to provide compensation). This claim is recognized by the courts and is often the basis of collection/subrogation lawsuits. The insure would have a claim against the insured as well since the payment was made on their behalf.

Re: Overpayment refund request

These cases can be very complex. One has to pay atention to the fact pattern, since a small difference in the facts that led up to the erroneous payment can make a significant difference in the outcome.

The other response that was posted did mention the primary avenue by which an insurer can seek relief: restitution to prevent unjust enrichment. But sez who the payment is UNJUST? If you rendered services and were paid a reasonable amount for those services, you have not been enriched unjustly! On the other hand, the patient/insured may be in a bit of hot water, since the terms of his or her coverage might not have provided for payments at this level to an out-of-network provider. Indeed, I think the insurer is, legally, on better ground going against the insured, who has benefited from payments that are not supposed to have been made under the coverage. Practically, it may be a tad bit harder to collect from an insured than from a physician. But none of that goes to the provider's exposure.

Assuming that you have no agreement of any kind with the carrier and you did not file an application for payment as an in-network provider, there does not appear to be any exposure at all on your part.

Please bear in mind that this posting is not legal advice. The cute phrase is "If it was legal advice, it would come with an invoice." The reality is that without actually taking a close, professional look at all of the facts (you understand the importance of Hx in arriving at a proper Dx and prescribing the right Tx), a lawyer cannot advise about your legal rights and liabilities any more than you would diagnose strep pharyngitis over the telephone. Especially if the patient turned up a week later with Lemierre Syndrome (such a case, I am now handling and it ain't pretty).