Legal Question in Insurance Law in Texas

Gastric Bypass

Last year, I had gastric bypass surgery performed successfully. I could not find a physician within my health care network who was performing gastric bypass at that time. An out-of-network surgeon promised to ''negotiate'' with my insurance company, and I agreed. I paid him $1800 up front, and he said that I would be responsible for the remainder, which would be ''about $1200''. The surgery was over $10,000, of which my insurance company paid the ''maximum allowable amount'' of $4000, even though they are supposed to pay 80% of ALL costs of out-of-network doctors. Now my surgeon is sending me a bill for $8000, and my insurance company says that because I waited over six months, I cannot appeal. What are my legal options and do you suggest a settlement?


Asked on 11/03/05, 10:41 am

1 Answer from Attorneys
Blair Brininger Blair Brininger

Re: Gastric Bypass

Your insurance company may not be able to assert the 180 appeal rule. That is the rule but the 180 days only start to run if the insurance company does everything correct when it limits your claim.

You should consult with an ERISA lawyer to discuss your options. We do telephone conferences but we do have a $200 consultation charge.

I cannot tell you whether to settle. I can tell you how much it will cost to litigate the claim and then you can make a business decision about setlement. Besides it takes two to settle. If the doctor insists on the whole amount you will have no choice but to select a non-settlement option.

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Answered on 11/03/05, 11:22 am


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