[Titlehelp]

My sister has cancer. She has insurance. The radiology firm who performed the radiation service on her brain is an approved provider on her plan. There were several professionals called in for this highly specialized brain radiation process. We are grateful for their service, but it was not disclosed that one of the brain surgeons who was brought in to oversee the treatment and administer shots to number her skull for the head gear, etc. was not an approved provider on her insurance. The insurance company issued a check for approx. $9,000 payable to my sister. They did not pay the doctor direct, because they say he is not on their preferred provider list. She was getting ready to send the check to the doctor but noticed that their bill said that she has to pay the balance due of $53,000.

Were they obligated to tell her upfront the estimated cost of this doctors services and the fact that he was not under contract with her insurance company. Don't they have to give estimated costs for services like any other professional service when the cost is in the thousands?

Had she known this, we could have made arrangements to go to the bay area, etc. where she would have had coverage.

[JudyKayTee]

My sister has cancer. She has insurance. The radiology firm who performed the radiation service on her brain is an approved provider on her plan. There were several professionals called in for this highly specialized brain radiation process. We are grateful for their service, but it was not disclosed that one of the brain surgeons who was brought in to oversee the treatment and administer shots to number her skull for the head gear, etc. was not an approved provider on her insurance. The insurance company issued a check for approx. $9,000 payable to my sister. They did not pay the doctor direct, because they say he is not on their preferred provider list. She was getting ready to send the check to the doctor but noticed that their bill said that she has to pay the balance due of $53,000.

Were they obligated to tell her upfront the estimated cost of this doctors services and the fact that he was not under contract with her insurance company. Don't they have to give estimated costs for services like any other professional service when the cost is in the thousands?

Had she known this, we could have made arrangements to go to the bay area, etc. where she would have had coverage.

I don't know about your particular insurance company but isn't there some sort of appeal process? We had this same problem when my husband had emergency surgery and the Neurosurgeon was not a covered provider. We appealed and argued that it was an emergency situation, the hospital/Doctor either should have or did know there was no coverage - and we won the appeal.

I'm a little confused about the $9,000 check - was it a partial payment to the surgeon? If so, then you are talking about coverage limits, not a flat denial.

And, no, they don't give estimates in advance, not where I live.

This sounds like a stressful (to say the least!) situation for you and your sister without having to deal with medical bills - hope it works out well in all aspects.