I'm having an issue with Pediatrician not covered by insurance.....?
I work for a Carita's Christi group in Boston area...My plan is Tufts, but its carried through The Roman Catholic Archdiocese of Boston. I need to know if what they are doing is right. I don't know much about how insurance companies work...Both of my kids have been seeing their pediatrician since the day they were born. My daughter is now 6 and my son, soon 4 years. I have always worked under the Caritas Christi Company. I first worked 4 years ago at a medical center then last April I left the Center and started working for another group, but still under the Company of Caritas Christi....but this company, unlike the one I worked for previously, will not allow you to see any Dr outside the Caritas Christi network. SO the Pediatrician that we have been seeing for the past 6 years (and saw throughout my employment with the medical center) is now not covered because he is affiliated with a differnt hospital. Is this legal? Are they allowed to dictate who you can see or not see? I mean I understand its their company...but, Just because I work for these people...doesn't mean I think they are good enough to take care of my kids. I trust the Dr I've been using for 6 years...How can I fight this? Who can I speak to? I've already contacted the Coordinator through my company and she is going to get back to me. I just don't think its right that a company has a right to dictate who you see as a physician. The hospital that my insurance covers....I don't trust their abilities. I wouldn't want to go there if anything happened to me, let alone my kids. I'm so beyond frustrated! Someone please explain to me if what this company is doing is right...because its actually not even the insurance company...MY pediatrician is covered by tufts! He belongs to the Tufts network. SO I know Tufts will cover him...but my company won't allow it. :o( I thought this would be the answer I would get.... Does't make me very happy! Great answer though...You spelled it out perfectly clear for me! Thanks.
Asked By: armywife - 11/13/2008
Best Answer - Chosen by Asker
Yes, it's legal. You have what is called an Health Maintenance Organization (HMO). You must use their doctors. Under a Preferred Provider Organization (PPO), which is sounds like you had before your move, you can see any doctor you wish but at a much higher co-pay cost to you... More
Answered By: Dan B - 11/13/2008
Additional Answers (2)
Yep, it's legal. We switched insurances at my job this year and my co-pays for doctor's and prescriptions went through the roof! I took my son to his ashtma doc last night and the co-pay was $50. I mean, it's ridiculous!!
Answered By: byrdie - 11/13/2008
Yes, it's legal. They cannot dictate who you can see, but they CAN refuse to PAY for someone who is not "in network". "In Network" means, they have a contract with that doctor. If they don't have a contract with that doctor, they don't have to pay, or at least, they won't pay "in network" rates.
Answered By: Insurance Geek-ette - 11/13/2008
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