Legal Question in Insurance Law in Pennsylvania

I saw an out-of-network (OON) doctor in Nov 09. Before making the appt I checked with Aetna about my OON benefits and they said I'd pay 30% coinsurance on the agreed-upon rate between the doctor and Aetna. I also checked with the doctor, who said he took Aetna insurance, and agreed I'd only be billed the 30% coinsurance.

I received a letter from the doctor Dec. 29th stating, "as you are well aware I've been in a long-standing dispute with Aetna...". I was not aware of this. He says that Aetna has withheld payments since April, he's tried to let it impact his patients as little as possible but he can no longer afford to do so and I need to pay my balance of $8000. This was the only sort of "bill" I got. On 1/2/10 I rec'd a letter from his attorney, saying my acct. was in default and I had to pay.

Was it illegal, or just unethical, for the doctor to not let me know about this dispute with Aetna? I would not have gone there had I known! And I don't have $8000. What do I do? Please help.


Asked on 1/13/10, 1:33 pm

1 Answer from Attorneys
Richard Teitell Richard K. Teitell, Esquire, P.C.

1. Call Aetna customer relations & see what the rep says about why they're not paying

2. As I understand it, most Aetna policies have a deductible for OON. Aetna will not pay until you reach the deductible. Find out if there is an OON deductible on your policy & the amount.

3. You should write a letter to the attorney indicating that a-his ltr is in error in that you had no prior information about the doctor's billing issues with Aetna; b. the doctor indicated you would only be obligated to pay 30%; c. you are prepared to pay 30% in exchange for a full release. You may want to hire an attorney to write the letter for you.

4. Good luck!! Contact my office if I can help you further.

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Answered on 1/18/10, 2:13 pm


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