Can my HMO pay for outside opinion as to hand and finger healing?

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Can my HMO pay for outside opinion as to hand and finger healing?

I had rotator cuff surgery about 5 months ago and my hand and fingers were adversely affected. I’ve had in-house therapy since then but is has not been successful. If I went to an outfit that specialized in orthopedic surgery, should my HMO pay for it as second opinion? I’m on Medicare and am 73 years old.

Asked on June 5, 2019 under Insurance Law, California

Answers:

SJZ, Member, New York Bar / FreeAdvice Contributing Attorney

Answered 2 years ago | Contributor

HMOs generally will not and do not have to pay for out-of-network consultations or services; typically, it is a PPO plan that will do that. Your health insurance plan is a contract; the insurer only has to pay for those services which the policy states they must. Read your policy to see what they have to pay; they do not need to pay for anything not covered by the policy.


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