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  1. #1
    Join Date
    Jun 2006
    Location
    Massachusetts
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    24,521

    Default Re: Scammed by My Dentist

    Just to clarify a few things:

    You and your insurance carrier have a contract that, when certain conditions are met, they will pay for covered expenses in exchange for your paying premiums.

    You and your dentist have a contract that he will provice certain services in exchange for payment.

    Your dentist is not a party to your insurance contract; your insurance company is not a party to your contract with the dentist. The only person who is involved in both contracts is YOU.

    If the conditions of the policy are not met, your insurance carrier has no obligation to pay.

    Your dentist provided the services; it now falls to you to provide the payment.

    Unless your policy specifically, and I mean in so many words, states that the dentist is responsible for the submission of claims, then the fact that your dentist did not submit the claim does not excuse you from fulfilling your part of the contract - that of payment. It is a courtesy, not a requirement, that he submit the claim for you. You, and only you, are responsible for the submission. The fact that he claimed to have done so does not change the fact that the responsibility to see that it was done, is YOURS. Remember, he is not a party to your contract with the insurance carrier.

    So yes, you are still liable to pay the bill.

  2. #2
    Join Date
    Sep 2009
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    2

    Default Re: Scammed by My Dentist

    Quote Quoting cbg
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    Just to clarify a few things:

    You and your insurance carrier have a contract that, when certain conditions are met, they will pay for covered expenses in exchange for your paying premiums.

    You and your dentist have a contract that he will provice certain services in exchange for payment.

    Your dentist is not a party to your insurance contract; your insurance company is not a party to your contract with the dentist. The only person who is involved in both contracts is YOU.

    If the conditions of the policy are not met, your insurance carrier has no obligation to pay.

    Your dentist provided the services; it now falls to you to provide the payment.

    Unless your policy specifically, and I mean in so many words, states that the dentist is responsible for the submission of claims, then the fact that your dentist did not submit the claim does not excuse you from fulfilling your part of the contract - that of payment. It is a courtesy, not a requirement, that he submit the claim for you. You, and only you, are responsible for the submission. The fact that he claimed to have done so does not change the fact that the responsibility to see that it was done, is YOURS. Remember, he is not a party to your contract with the insurance carrier.

    So yes, you are still liable to pay the bill.
    Really? So you're saying I don't have any case here. But basically a victim of another person's incompetence. Isn't it a common practice for the dentist, doctor etc.. to submit the claim to the insurance company!? I have never been responsible for submitting my own claims.

  3. #3
    Join Date
    Jan 2008
    Posts
    1,948

    Exclamation Re: Scammed by My Dentist

    It is courtesy provided by some/most medical providers - BUT they are under absolutely no obligation to do so. I'd be willing to bet that your dentist even has a form that you signed stating that you are responsible for paying for all services rendered regardless of insurance coverage.

  4. #4
    Join Date
    Jun 2006
    Location
    Massachusetts
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    Default Re: Scammed by My Dentist

    The fact that your dentists and doctors have previously, as a courtesy, submitted claims for you does not change the fact that they are not obligated to do so, and that in the absence of a clause in your insurance policy that very specifically says, "You are not responsible for filing the claims - your dentist is responsible for doing so", the ONLY person who is responsible for filing a claim or seeing that it is filed is YOU.

  5. #5
    Join Date
    Sep 2009
    Posts
    5

    Default Re: Scammed by My Dentist

    Quote Quoting cbg
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    The fact that your dentists and doctors have previously, as a courtesy, submitted claims for you does not change the fact that they are not obligated to do so, and that in the absence of a clause in your insurance policy that very specifically says, "You are not responsible for filing the claims - your dentist is responsible for doing so", the ONLY person who is responsible for filing a claim or seeing that it is filed is YOU.
    I'd like to see if any case law that supports this anti-intuitive belief.

    If a medical provider says that they have filed a claim, but does not, and as a result the patient loses the opportunity to file the claim, then the medical provider is at fault.

    This medical providers actions certainly meet 8 or the 9 elements of common law fraud, with the only point in contention being, "plaintiff's right to rely upon it" the it being the assurance that the claim had been filed.

    http://en.wikipedia.org/wiki/Fraud

    The idea that a patient has no right to rely on the word of a medical provider in the matter of whether a claim has been filed, but that the patient should rely on the doctors word on matters of life or death seems odd to me.

  6. #6
    Join Date
    Jun 2009
    Location
    California
    Posts
    666

    Default Re: Scammed by My Dentist

    Quote Quoting cbg
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    and that in the absence of a clause in your insurance policy that very specifically says, "You are not responsible for filing the claims - your dentist is responsible for doing so", the ONLY person who is responsible for filing a claim or seeing that it is filed is YOU.
    There actually is a whole class of health insurance policies now in which this is true. The concept of "in-network" charges in which the insured is either required or strongly encouraged to use providers within the insurance carrier's network for the policy involved. When receiving services from an in-network provider, the provider must do the billing; the insured cannot. There is an actual contract between the insurance company and the provider in which the provider agrees to accept the insurance company's payment and determination of how much the patient owes.

    I don't know if this applies to all states, since insurance is regulated by the states.

  7. #7
    Join Date
    Jun 2006
    Location
    Massachusetts
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    24,521

    Default Re: Scammed by My Dentist

    I'm aware of that; I used to work for the insurance company that premiered the concept. That's why I was so specific about what the policy had to say. The poster now knows what to look for in the policy. If s/he finds it, great, s/he can bring it to the attention of the dentist, or, for that matter, the provider relations department of the carrier. If s/he doesn't find it, though, s/he is stuck with the bill however much s/he feels s/he shouldn't be.

    This kind of clause is, however, still the exception rather than the rule, and generally exists only with managed care plans.

    mfurlan, perhaps you can show me something a little more substantial than a wikipedia article that excuses a patient from paying a doctor, or taking responsibility for seeing that it it submitted, simply because in the past other doctors or dentists have submitted claims for them. At any time during the year in question, the patient could have called the insurance carrier and found that the claim had not been submitted. At any time during that year, the poster could have submitted the invoice he received at the time of the billing (and the patient, in my experience, is ALWAYS given an invoice showing the treatment codes and any copays already made) to the insurance company directly.

  8. #8
    Join Date
    Sep 2009
    Posts
    5

    Default Re: Scammed by My Dentist

    Quote Quoting cbg
    View Post
    I'm aware of that; I used to work for the insurance company that premiered the concept. That's why I was so specific about what the policy had to say. The poster now knows what to look for in the policy. If s/he finds it, great, s/he can bring it to the attention of the dentist, or, for that matter, the provider relations department of the carrier. If s/he doesn't find it, though, s/he is stuck with the bill however much s/he feels s/he shouldn't be.

    This kind of clause is, however, still the exception rather than the rule, and generally exists only with managed care plans.

    mfurlan, perhaps you can show me something a little more substantial than a wikipedia article that excuses a patient from paying a doctor, or taking responsibility for seeing that it it submitted, simply because in the past other doctors or dentists have submitted claims for them. At any time during the year in question, the patient could have called the insurance carrier and found that the claim had not been submitted. At any time during that year, the poster could have submitted the invoice he received at the time of the billing (and the patient, in my experience, is ALWAYS given an invoice showing the treatment codes and any copays already made) to the insurance company directly.
    You are not responding to what I wrote.

    My question remains:

    If a medical provider tells a patient that they have submitted a claim, knowing that they have not, and that misrespresentation caused the patient to lose coverage for those services, does the patient still have responsibility to pay?

    Or what about a medical provider who doesn't even bill for a year and a day? Or 10 years?
    Are there no limits?

    I'm sure all these matters have been litigated.

    If nobody knows the case law, I'll check elsewhere.

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