Do I have claim vs. my health insurer for overcharges due to wrong advice & subsequent denial of coverage requiring appeal?

Asked 10 months ago - Devon, PA

In 2011 I went to office of health insurer to enroll in PPO on the spot so I had to take costly guaranteed-enrollment plan. I asked if they had cheaper medically-underwritten plans. Sales agent said no. I asked again if they had plans like that I could apply for for the future. Again, no. So I enrolled in costly PPO. Last year I found out agent was wrong (company's website is no help, so it took a while.) I am healthy so I applied for the underwritten plan. I was denied based on diagnosis codes on doctor bills for things I didn't have. I appealed and won but it took months to gather my records for the appeal, during which time I was still paying $850/mo. when I qualified for $440 plan. Can I recover overpayments due to wrong advice by sales agent, or for during appeal period? Cont'd

Additional information

What irks me is that I overpaid for 2 years due to being given wrong advice by their agent regarding available plans, and then when I finally learned the truth and applied for underwritten coverage, they turned me down based on non-existent things that it should have been clear to them that I didn't have because there was no treatment ever given. They'd have known about it if I had anything serious because they were my insurance company. E.g., I went to a cardio because I was having palpitations that turned out to be benign and the doc's office somehow put "atrial fib" as a diagnosis code on my bill. Believe me, there was no possibility of mistaking these occasional palpitations for a-fib. And wouldn't I have been treated for it? I feel like I'm owed a set-off for overpayment due to bad advice & during the appeal period since I should rightfully have been accepted into the plan.

Attorney answers (1)

  1. Ryan Michael Davidson


    Contributor Level 15


    Lawyer agrees

    Answered . This isn't generally the kind of thing that can serve as the basis for a viable cause of action. They issued the policy they believed you to be entitled to under their underwriting rules given the information you had provided. It's not their fault that there was a problem with your records. They might be willing to cut you a deal given your situation, but they may not.

    I think you might do best by filing a complaint with the Department of Insurance. They take over-charge issues fairly seriously. That'd be a place to start, anyway.

    This answer does not constitute legal advice and does not establish an attorney-client relationship.

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