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Complaint 0 of 0 in "Errors in Claim Payments"

Insurance Carrier: United Healtcare
State: Ohio

Consumer Complaint:

The patient was concerned about her deductible and out of pocket expense. He was not able to afford to have laser surgery for diabetic retinopathy. When United Healthcare was called to check on benefits, patient was quoted 100% with no deductible. When payment received from United Healthcare, the patient had $500 deductible with 80% coverage. On follow up with UHC, they said we were quoted office surgery benefits, not outpatient benefits. Claims sent to Appeals with the carrier and after review claims paid correctly, even though incorrect benefits quoted. Patient would be responsible.


Insurance Expert Answer:

This happens all the time. Except in the most rare of circumstances, the insurance carrier is only obligated to pay for the benefits the policy provides, and is not bound by the phone center's statement to the patient or provider. If a staff member makes a mistake in interpreting the policy, it is not liable for the mistake. In fact the introductory message on the phone line "This call may be monitored ... and nothing said will change the terms of the policy, which govern ...." often says that. There are many strong public policy reasons for that. Sometimes the provider or patient gives an unclear description to the carrier. There are many different flavors of policy out there and each treats things a bit differently. The clerks who answer the phone at the call center are not trained lawyers. Sometimes the person making the call hears something different from what the clerk said. In such circumstances most providers make some accommodation to the patient, and they share the "loss."