We consulted our attorney several years ago, who told us basically that if coverage is quoted, and they have the same plan when services were rendered, then they have to pay.
No disrespect to the attorney but he was not correct. I've seen cases where appeals were not granted, it's the whole reason they inform you either directly or by recording that "This is not a promise of payment... etc etc etc" Reason being is that many policies do have changes that take place in the intrim between services verified and claim submission. A good example is patients with a COBRA plan and don't pay their premium, there's a grace period for them to get their payment in so the carrier does not input a termination date, claim gets processed, the insurance company has a right to request it back if premium isn't paid. Another example is a plan that might change from an 80/20 plan to a 60/40, etc.. etc.. in between verifying benefits and claim submission. Those are unavoidable things. More than 95% of claims processed where benefits were misquoted are correctly denied. They are not even considered "misquoted" again, because policy changes during that period are unavoidable. In simple terms... NO customer service rep or claims examiner has a crystal ball. Oh and one other thing.. If you look at your own insurance policy handbook, that's quoted the same way the disclaimer reads when you call the carrier. That's why that attorney was incorrect, it is not cut/dry that a carrier has to pay based on what they quoted you.
