What are our rights regarding a denied health insurance claim?
Question Details: My wife has had chronic shoulder pain for several years. We went to our family doctor who ordered an MRI at an imaging center. The doctor claims that she told us to wait for approval from the insurance company but we do not recall that statement ever being made. We scheduled the MRI and had it done, and about a week received a letter saying that the claim had been denied because more conservative treatments had not been completed. The imaging center did not notify us when scheduling or before the procedure that the claim had not been approved yet. Is it legal for a doctor/imaging center to schedule and perform a procedure without notifying us that it has not been approved by the insurance company?
Yes, it is legal for them to do this. It is the responsibility of the insured person, not of the health care provider, to make sure that there is coverage; that is, it was legally your responsibility, not the doctor's or imaging center's, to make sure you were covered. Since it was not their responsibility, they are not liable for the failure for you to be covered; and since it was your responsibility, you have to pay the cost if it was not.