Need suggestion for a claim denial issue

I have question that is a bit of complicated related to claim denial and would like some advice on what to do next.

Here's the story: I was an international student and purchased an insurance product from DIANins (insurance agency: DIANins, insurance company: Wellaway) as an alternative to school medical insurance. This April, I took an MRI exam because of TMJ disorder. My healthcare provider communicated with the insurance customer representative and was informed that no pre-authorization was needed for MRI exams and told me to go to the imaging institute right away. However, after 3 months, I received a bill of 1900 dollars. The claim was denied, though the insurance company claimed that no pre-authorization was needed. I contacted the insurance company and presented the reference ID of the call that my healthcare provider made. The insurance company responded that yes no pre-authorization was needed for MRI exams but we didn't say that the MRI itself was covered because TMJ disorder was excluded in your insurance and your healthcare provider didn't provide your diagnosis when making the call.

Okay. A 1900-dollar bill to pay. I felt that all parties contributed to this outcome. Coz I'm not familiar with the standard procedure of medical examinations and insurance consultation call, so please give me suggestions on all these stuffs:

The insurance company is the most phishy one. The purpose of my healthcare provider's call was to check if I was eligible to take the MRI, and they just answered that no pre-authorization was required. They said that my healthcare provider didn't provide my diagnosis, but they didn't ask about it as well. (My biggest confusion: who should be responsible to start the conversation of diagnosis? The insurance company or my healthcare provider) The insurance company also did some misinterpretation when they were doing commercial campaign. They only listed favorable terms in their summary and didn't list the exclusions, which should be against the ACA. I really should have read the policy before taking the examination, but it was 40 pages. Yeah this can be taken as an excuse, but it was 40 pages with all those medical terms. There is only one sentence that the TMJ disorder was excluded. I suppose it was almost impossible to read through all the pages without skipping any sentence. My healthcare provider didn't provide my diagnosis and took the answer as it was covered in my insurance. I'm not sure what is the standard procedure for healthcare providers making confirming calls with insurance companies, so I'm not sure if it should be my healthcare provider that needed to make it clear. The imaging institute didn't provide an estimated cost before the examination. I did ask about how much should I pay or something like that and they responded that I was all set and it was covered in the insurance. I'm also not sure if there is a standard procedure that the imaging institute should provide an estimated cost.

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Then I contacted with all these parties.

The insurance company is the most disgusting one. I reported to NAIC about the misinterpretation they made in their official website and it turned out that Wellaway was established in Bermuda, so NAIC has no authority on them. Wellaway's official response was like "yes we didn't list the exclusions in our summary because our insurance products are not ACA products so we do not need to obey these rules". For the dispute of the call they made, they said that since the diagnosis is excluded, they won't resolve any dispute, which is logically purely nonsense. But anyway, since Wellaway is established in Bermuda and Bermuda doesn't seem to have any supervision upon their insurance companies (I did try to contact but no response), it seems that it's impossible to resolve the issue due to the lack of a third party.

My healthcare provider didn't respond to me. I wrote four mails. No response. Since I now get back to my home country and deactivate my US number, it was not likely to make a phone call with them.

I asked the imaging institute of giving a discount. They refused in the first place and told me to call to make a payment plan. I said that my US number was deactivated and asked whether it is a standard procedure to present the patient with an estimated cost. Then they agreed to give me a 20% discount with the limitation that it should be paid in 2 months. They didn't answer whether presenting the estimated cost is a standard procedure or not. I'm a bit confused in their change in attitude. Are they worried that it is impossible to find me as I'm residing in my home country? Or it should be a standard procedure?

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So here is the story. Any suggestion is much appreciated! Here are my confusion and concerns regarding all three parties?

Is there any organization that can deal with Wellaway, the insurance company in Bermuda? (I doubt it… They establish the company in Bermuda to avoid supervision. But it would be nice if there is a way) Should it be my healthcare provider that spontaneously provide my diagnosis during that kind of call with the insurance company? If so, is there any organization that I can turn to for help? Is there any standard procedure that the imaging institute should provide the estimated cost in the first place? If so, is there any organization that I can turn to?

Thanks again for reading it and for any suggestion!! It was almost blowing my mind for the past months. I was blaming myself for not going through the policy thoroughly and not doing a double check with the insurance company, but I also felt like I wouldn't know where to start because everyone else was taking it as the exam should be covered in my insurance. I felt like my healthcare provider asked reasonable questions in the call and the insurance company aswered question and the institute took it as it is covered in my insurance and everything just sounded so reasonable but they all seem to be beating around the bushes and lead me all the way to the bill. It is just so subtle!!

submitted by /u/Murky-Resolution6100
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