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Insurance Carrier: Qualcare
State: New Jersey

Consumer Complaint:

My wife needed breast surgery for breast cancer. Qualcare paid a dismal amount because I wanted to use my out of network surgeon that we have had for years.


Insurance Expert Answer:

I am sorry to hear about the illness, and the fact the insurance company will not pay. In general, and always in the absent compelling circumstances, the insurance company will insist on the strict enforcement of the terms and conditions of the policy.

When it comes to in and out of network, the companies cut special deals with network doctors and hospitals whereby they significantly drop their fees in exchange for an assured flow of patients. To encourage the people covered to go in network, the health plans pay a far smaller percentage for out of network services. Make sure you follow the deadlines on appeals, but I fear it will be fruitless.