Legal Question in Insurance Law in Pennsylvania
Insurance bill submitted higher to cover full payment
I had tmj surgery 8 years ago on my left jaw due to a car accident-2 years later after another accident I had to have it on my right side. The first acc. my auto insur. covered most of the bill and the remaining Blue Cross Blue Shield picked up after the 2nd accident most of the bill had to be paid thru B.C B.S. well this Dr.Tenzer that did the surgery took me into another room and explained the reg fee then he said that he was going to submit a consid. higher fee because B.C.B.S. pays a % so I thought fine as long as I didn't have to pay anything well anyway they rejected claim due to the 1st surg. being pd. so now he's been coming after me for the full amt. I've been paying $20 a month and I rec a letter today stating that its being turned over to the magistrate. Can he do that? I've contacted B.C.B.S. after the billing rejected the claim but they couldn't do anything. HELP!! ASAP! My settlement was around $5000 due to being damaged goods-this payed my other bills off. I had nothing left to pay him. Can he take all the $ that we put in the checking account to pay bills?? We have direct deposits. My mortgage has to be paid!
2 Answers from Attorneys
Re: Insurance bill submitted higher to cover full payment
The following is based on the facts you provided and PA law.
You should attempt to contest the amount of the bill the doctor is attempting to enforce against you if you beleive it is the product of an attempted fraud. It is hard to give specific advice without knowing more of the facts.
If you would like to discuss the matter in more detail please contact me.
Patrick W. Carothers
(412) 355-0200x6153
Re: Insurance bill submitted higher to cover full payment
You need to consult an attorney to review the facts.
If you had an actual settlement agreement with the doc where he said he'd take $20 per month until it was paid, that might be a defense, but you'd have to prove that was the terms of the agreement.
It's possible, under the BC/BS regulations, or his agreement with Blue Cross, that he might be obligated to accept their payment amount. It sounds like you didn't appeal the BC/BS denial so it may be too late.
Your attorney will have to look at the PA auto insurance law. Your PIP coverage should have covered expenses in the second accident, up to the limit, if you were insured. And that law also forbids doctors from "balance billing," i.e., charging the difference between the approved insurance amount and what they want to charge.
If the doctor does sue, you'll need a lawyer to defend yourself, so it's better to consult one now.
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