[radgumbo]

My wife went to her doctor because she was feeling ill. Her physician's asst. saw her and diagnosed she might have a pulmonary embolism and sent her immediately to hospital for a spiral cat scan. Once at the hospital she was asked if the test had been authorized by her insurance company. She tried calling the Doctor's office several times to check but, she could not get through because the phone's were off for lunch hour. Thinking she might have some serious illness or stroke she signed a contract with the hospital to pay should the insurance company refuse to pay. Turns out nothing serious, insurance company refused to pay and again refused after appeal but, basically stated that my wife should not have to pay because the Doctors office should have seen other possibilities for her symptoms based on her medical history before ever ordering the cat scan... unless however, she had signed an agreement with them to perform the test. She feels that she signed the contract under duress because she was given the impression by the physicians asst. that she might be seriously ill and might even die if she didn't have the test performed. Later on after receiving bills from the hospital for payment of the test, she called her Doctor and explained the situation and was told her not to worry that they would take care of the situation by writing the insurance company and get the matter taken care of... the insurance company refused and we are now being sued by the hospital for payment. Does my wife meet the criteria of signing under duress? The letter from the insurance company basically gives us the impression that the Doctors office misdiagnosed her symptoms and that she shouldn't have to pay. How do we prove she signed under duress?

[excon]

Hello rad:

I don't understand what happened. IF your wife was insured, and the insurance company is refusing to pay, sue them. Small claims court is quick, cheap and easy.

excon

[ScottGem]

Before suing your insurance carrier, see if there is a state agency that oversees insurers and bring your case to them. Insurers should not be making diagnoses.

[JudyKayTee]

She agreed to pay for any charges that were not paid for by her insurance. Your recourse is to pay the bill and then sue the health insurance carrier - you may win, you may not.

If she had not had the test and had, in fact, been a high stroke victim, then you would be posting this from another angle.

The hospital is going to argue it was a medical necessity and the insurance company is not staffed by Physicians.

I've been there, done this, with my late husband. When you are in that hospital and told you need this test or that test, you sign. Later you worry about paying for it.

[radgumbo]

Ok... I understand what you are saying. However, the health insurance (Blue Cross/Blue Shield) had their panel of experts review our appeal and they are saying that the Doctors office that ordered the test should have ruled out other things first before ordering the test in the first place... basically saying that the test was unfounded further saying that my wife shouldn't have to pay... unless she signed a contract (which she did, "under duress"). My point is, the Doctors office was supposed the get the pre-authorization and they didn't... when my wife arrived at the hospital that was when she was asked if the test had been authorized... when she couldn't get through to their office, she signed the contract because she thought her life might be at stake and that the insurance would cover it. It appears that she was misdiagnosed... maybe we should be contacting her Doctors office... ex Doctors office by the way. After all they were supposed to get the authorization, weren't they?

[Fr_Chuck]

Don't matter what BC/BS did, it was their own employees reviewing it, who do you think they will normally go with.

And it does not matter about "contract" in fact even in standard admission forms, it states normally, that you have to pay if your insurance does not.
She could have waited and verified benefits, in fact the hospital has ( most do) an entire staff that does nothing but check benefits.

Actually the patient is obligated to get the pre authorization with BC, not the doctor, normally the doctor does it but it is the patients final responisllbility to see it is done.

You have no case what so ever against the hospital.
Perhaps a slight one for a wrong idea, but again that was what the test was for, to prove if or if not

I don't see a case against anyone but BC/BS myself

[ScottGem]

You have to pay this bill and then sue BC/BS and the doctor. BC/BS should not be making medical decisions. Maybe there were other things the doctor could have tried, but he was on the scene, with the patient. That trumps some bureaucrat sitting at a desk reviewing the case from hindsight. On the other hand, both the doctor and the hospital should have tried to get pre cert of the procedure. Insurance carriers have a 24/7 staff for such things.

[PellMell]

Does my wife meet the criteria of signing under duress?

From law.com:

Duress occurs when a wrongful act, a threat or coercion is used to force a person to enter into a contract against her will. Duress may exist even though a person is fully aware of the nature and consequences of her act.

On this issue the burden of proof is on the defendant. This means that the defendant must prove, by the greater weight of the evidence, that she entered into the contract with the plaintiff as a result of duress.

Factors to be considered: The defendant's age, physical condition, mental condition, access to or opportunity to have independent advice, the fairness of the transaction, the existence of independent consideration for the transaction, the relationship between the defendant and the plaintiff, the value given up by the defendant in the transaction compared to the defendant's total net worth, the degree to which the plaintiff sought or solicited the defendant to enter into the transaction, the degree to which the defendant was already susceptible to pressure or coercion by reason of personal distress, other situation supported by the evidence.

This rule says that you must establish that a wrongful act, a threat, or coercion caused your wife to sign the contract against her will. What is the wrongful act? What was the threat? What was the coercion? Did she object to signing the contract? Those are some of the questions you would have to answer in court if the definition of duress is the same in your state as it is in mine.

[radgumbo]

PellMell... excellent answer. Thanks to everyone one else for their advice as well. It seems to me that if a person is in fear for their life which was caused by the Doctor's office (Physician Asst.) telling my wife she may have a pulmonary embolism and that they sent her to the hospital for a test. The physicians asst. made the appointment for the test with the hospital. She immediately left the doctors office to go have the test. Once she arrived at the hospital she was asked about the pre-authorization. She said she felt sure that there was because the doctor office had made the arrangements. When she tried to call the doctors office to verify this, she couldn't get through after 4-6 attempts because they turn off the phone system during their lunch hour. Because her scheduled appointment time was basically upon her arrival, she felt pressured or compelled to sign because of the urgency of the situation... i.e. if she didn't get the test she might have a stoke or something. She was very upset and thinking she might be deathly ill. There was nobody for her to talk with and she signed the papers.

[radgumbo]

Oh, by the way... BC/BS had medical experts (Doctors) review the appeal...

[PellMell]

My argument would be against BCBS that there were exigent circumstances based on the medical advice she was given at the time.

[Fr_Chuck]

Oh, by the way...BC/BS had medical experts (Doctors) review the appeal...

Yes they do, all of who of course have a vested interest being paid by them.
It was like the "independent" board we had in the federal prisons, they were made up of all prison staff, with at least one from security who normally had written up the complaint. And the inmate got another prison employee to represent them.

So you had a lot of buddies, who worked for the prison, deciding if the prison was correct in action against an inmate, guess who almost always won

[ScottGem]

So, instead of calling the doctor's office 4-6 times. Why didn't she call BCBS? Or why didn't she ask the hospital to do so? Medical providers have a more direct line to get such answers!

[JudyKayTee]

My argument would be against BCBS that there were exigent circumstances based on the medical advice she was given at the time.

So why isn't he arguing this with BC/BS?