What can you do when payment for your client's service is refused by their insurer?
We all know that the whole purpose of an insurance company is to make money and that some of them will stop at nothing to limit or eliminate the benefits they have to pay to your clients / patients. . In fact, very often insurers use all kinds of inaccurate pretexts to justify rejecting a claim with the goal of raking in millions of dollars in profits down the line.
When your patient / client is opposed to the reimbursement of an insurance claim for your services rendered, this does not mean the end of the process for your patient / client because it only marks a step leading ultimately to compensation in in most cases.
When an insurer does not respect the terms of your patient / client’s contract and refuses to pay their service as per the terms of your patient / client’s contract, regardless of the pretext for refusal, this is often only the case. ‘a tactic on the part of the insurer to discourage your patient / client from using the coverages of their contract and thus generate more profit in the end.
When this situation turns out, according to the law on insurance, under any circumstances your patient / client should abandon his dispute to force his insurer to respect the terms of his contract, because if the insured does not dispute, the abuse of his insurer’s share could persist and even worsen.
It should be understood that an insurance company is a company constituted by an NEQ number at the Registrar of Enterprises of Quebec (REQ), it is a company governed by the law on insurance, a company subject to the law of the Financial Markets Authority. So in the absence of government regulations regarding the practice of alternative medicine in Quebec, the fact that an insurance company is not a monitoring body mandated by the Quebec legislator, an insurer has no power to ‘investigation into the functioning of the CPMDQ or the assessment of the academic skills of its members, an insurer cannot therefore refuse to pay for a service on the pretext that the service provider does not meet the criteria and the insurer’s demands or even other pretexts prejudicial to the CPMDQ or to its member.
It is important to first understand group insurance contracts. In a group insurance contract, three distinct parties are involved, namely the policyholder (the employer of your patient / client), the insurer (the insurer of your patient / client) and the members (your patients / clients) .
The policyholder (your patient’s / client’s employer) is the party who concludes the insurance contract with the insurance company. It is this contract which describes the terms of the coverage offered and its content is binding on any person insured under this contract.
The participant is the person eligible for the contract who has completed an insurance enrollment form. (your patient / client)
The insurer (your patient’s / client’s insurance company)
The insurer is required to send the policyholder certificates attesting to the insurance coverage so that the policyholder can send them to each of the members (the policyholders). In practice, the insurer also sends the policyholder (the employer) brochures describing the content of the insurance guarantees that are given to each of the members (the insured).
For the above reasons, when an insurer refuses to reimburse a receipt issued by a CPMDQ member because of a reproach from the CPMDQ or vis-à-vis the qualifications of its member, in all likelihood this can only be a a pretext on the part of your client’s insurer to discourage them from continuing to use your services in order to eliminate a huge percentage of reimbursement requests by their insureds (your patients / clients).
However, as your patient / client is recognized as a true party to the insurance contract, when a dispute arises between your patient / client and his insurer, your patient / client has a direct legal relationship against his insurance company without have to go through his employer. In an insurance contract your patient / client is recognized as a true party to the contract, he has all the rights to contest the refusal of reimbursement and force his insurer to respect the terms of the contract.
Article 2405 of the Civil Code of Quebec provides that changes made by the parties to the insurance contract are recorded in an addendum to the policy. The parties in question here, in group insurance, are the policyholder and the insurer. The modifications made by them are opposable to the members, subject to the acquired rights of the latter.
Thus, when the insurer of your patient / client refuses reimbursement for his service provision for your services rendered, and we are talking here about services whose
Insurer and General Public Section, Refusal of payment by an insurer.
Outline of the CPMDQ c. SSQ