What to do if I received a medical apparatus which I was told would be covered under my insurance but the company failed to file the claim within 18 months?

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What to do if I received a medical apparatus which I was told would be covered under my insurance but the company failed to file the claim within 18 months?

Therefore the claim was denied. Am I liable to pay over $2,000?

Asked on October 1, 2012 under Insurance Law, Florida

Answers:

M.T.G., Member, New York Bar / FreeAdvice Contributing Attorney

Answered 9 years ago | Contributor

Here is the problem: the timely filing of submissions is part of the contract plan and you need to review that portion of your contract.  You also need to review the appeal process for the denial of the claim and file that right away.  Many contracts state that the insurance company is not obligated to pay the claim if submitted past the time for filing.  My concern for you is that you will be sued by the provider for the apparatus.  At that point in time you are going to have to defend your position: that you relied on the provider to obtain the apparatus on your behalf and with the approval of the insurance company.  That the provider breached its agreement with you and the plan by not filing timely.  Yes, you probably signed something that said you would pay the provider if insurance denied the claim.  But that assumed that the provider did not breach their agreement to timely file.  It may be a long haul but in the end you could be successful.  Good luck.


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