What can we do if our health insurance provider will not allow my daughter to see an out-of-network doctor?
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What can we do if our health insurance provider will not allow my daughter to see an out-of-network doctor?
We have been referred by an in-network provider to a pediatric neurosurgeon, who has access to the necessary equipment/facilities that could possibly relieve the continuous fight with epilepsy. The provider states that we have to exhaust their in-network facilities, however they do not offer one with what her PCP states is needed. The provider has not technically denied or issued what would be deemed as an adverse benefit determination. Only that they will not allow us to seek out the treatment with the out-of-network provider. I am continuously being roadblocked by claim personnel with no information for appeal.
Asked on January 20, 2016 under Insurance Law, Michigan
Answers:
SJZ, Member, New York Bar / FreeAdvice Contributing Attorney
Answered 8 years ago | Contributor
They can't stop you from seeing the out-of-network provider--you can go to any doctor you want--but you may have to pay the out provider entirely out of pocket. Health insurance is a contract; the insurer only needs to pay or provide coverage in accordance with the terms of that contract. No matter how much you need coverage, they don't have to pay otherwise. But you can get the treatment--as long as you pay.
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