Insurance Denied Medical Claim

[hayew]

My question involves insurance law for the state of: Virginia

My insurance company denied a claim submitted for an operation to place tubes in my son's ears (son was 2 yrs old). Due to frequent ear infections, our doctor said the tubes were necessary to help him. Insurance has paid only $116 of $5,000 in charges.

*Can the insurance company legally deny this claim?

*If the insurance company can legally deny, am I liable for the whole amount billed?

*Can/should I negotiate to pay "legal and customary" amount?
Thanks for any help!

[lwpat]

It depends on your policy. I have been successful in small claims but you have to follow the dispute procedure first. Sometimes the doctor will reduce when the insurance won't pay. Otherwise you are liable.

[Betty3]

Agree, you can dispute the bill but otherwise you are liable. Someone has to pay the doctor for the services rendered to your son.

You can see if the dr. will consider a reduction in the bill and/or monthly payments.

[cbg]

For some reason a great many people are under the impression that their insurance is required by law to cover anything that is deemed "medically necessary" by the physician. There is no such law.

The insurance company is only required to cover what is says in the policy it will cover. If surgically placed drainage tubes are not a covered benefit, then the insurance company is not required to pay for them. Even if you have a signed affidavit from the Surgeon General of the United States saying that they were medically necessary.

What does the policy say?

[momm2500]

What was the reason for denying the claim? Is it possible that they might have asked for additional information and you never submitted that? Can not help without knowing the reason they denied it!