by Guest » Thu May 14, 2009 06:45 pm
Hello guys,
I had been outside the country (to my home country) and became sick during that time. I was admitted and charged a bill by the doctor. I did pay all the money and asked my insurance agency whether I could file a claim or not. They said I could definitely submit one. I went ahead and they mailed me the money which I had deposited. About a month or so later somebody from the SIU sent me a letter saying that they are reviiewing charges against me (because they feel that the charges are high - I have just sent whatever the doctor has billed me). They had asked for an explanation of benefits form which I filled out and sent to them. They came back to me asking for day-to-day reports and doctor details and I have diligently sent everything over. Still they wanted to investigate further and they have actually carried out investigations in my home country.
The investigation into the claim is still ongoing. Now my question is - I am not sure what the outcome of the investigation report will be. If they do determine that the charges are higher than what they are supposed to be (according to them) - how will the process go from there? I am very scared because I have never been involved in any kind of investigation before and I have nightmares about my insurance company deciding that this is some kind of a fraud (which this is not!!!) and just sending cops to my home.
I had been outside the country (to my home country) and became sick during that time. I was admitted and charged a bill by the doctor. I did pay all the money and asked my insurance agency whether I could file a claim or not. They said I could definitely submit one. I went ahead and they mailed me the money which I had deposited. About a month or so later somebody from the SIU sent me a letter saying that they are reviiewing charges against me (because they feel that the charges are high - I have just sent whatever the doctor has billed me). They had asked for an explanation of benefits form which I filled out and sent to them. They came back to me asking for day-to-day reports and doctor details and I have diligently sent everything over. Still they wanted to investigate further and they have actually carried out investigations in my home country.
The investigation into the claim is still ongoing. Now my question is - I am not sure what the outcome of the investigation report will be. If they do determine that the charges are higher than what they are supposed to be (according to them) - how will the process go from there? I am very scared because I have never been involved in any kind of investigation before and I have nightmares about my insurance company deciding that this is some kind of a fraud (which this is not!!!) and just sending cops to my home.
Posted: Thu May 14, 2009 11:50 pm Post Subject:
IMHO, you should just keep the money and not waste your time with them any longer. You submitted the bill and _they_ determined the amount they owed and paid it. You considered this is what they owed and you no longer have their money. If they now want to say that they made a mistake and paid too much... too bad. You were led to believe that this was all covered and you relied on their actions to confirm this. They had every opportunity to review the bills. In that you took actions based on their payment, if they now want to go back on what is covered it would penalize you. They have no right to do that.
It's called Estoppel... they gave you the "impression" (to say the least) that they entire amount was owed and you relied on this information to take action (you spent the money). As asking for any of the money back would harm you, they cannot do that as they "implied" (just slightly) that they owed the full amount.
If you talk to their SIU department, mention that you feel that they waived their right to adjust the bill once they paid the claim and tell them that you feel that they are estopped from adjusting the bill at this time.
Posted: Fri May 15, 2009 01:27 am Post Subject:
To the OP :arrow: listen to what tcope said.
tcope- sweeeeeeet :idea:
InsTeacher 8)
Posted: Fri May 15, 2009 05:25 am Post Subject:
This is one good example about how the insurance companies goof up things.
By the way, can they actually send a case to the investigating department after paying the claim?
Posted: Fri May 15, 2009 10:57 am Post Subject:
(This answer is coming from someone without expertise in health insurance claims, but with lots of common sense.)
Isn't this the way that we would all want our insurance companies to behave? They acted in a trustful way. They received a claim and paid it.
The insurance company has two choices. 1) Delay paying the claim until it can be reviewed and then investigated. 2)Immediately pay the claim and then review and investigate. If they paid too much, ask for their money back.
Assuming that this claim is completely legitimate, the end result of the insurance company doing it the way that they did it will simply be that the insured gets his money back months sooner than if he had to wait for an investigation.
You can bet your bottom dollar that there was language in the letter which accompanied the check or in the policy itself, that allows them to adjust the bill after paying the claim.
Do we really want insurance companies holding onto our money until they are 100% sure that they are paying the correct amount? That is the alternative to what they did.
Guest, if they think that they paid you too much, they will simply ask for some of the money back.
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