I am posting for a friend because she just called me in tears about this and doesn't know where to turn. That being said, here is the background.

Friend has two HMO insurances. One is from her retirement and one is from her current job. About two years ago, she had an abdominal surgery for a GI issue mostly centralized in the stomach itself. After recovery, the excess skin began to continuously become infected and so she got approved to have the excess skin removed (not a tummy tuck - this is important bc it was not elective and actually medical). So, HMO #1 told her that they would pay for said surgery and did pay for it. There is a papertrail and proof that this happened.

Now, it's been over one year since the surgery happened and the plastic surgeons office sent her a notice today stating that she is responsible for the entire cost of the surgery to be paid in 30 days.

So, she talks to her insurance and they tell her that although HMO #1 approved and paid for the surgery, after some sort of evaluation, they decided that HMO #2 should have paid for it so they somehow took back their payment without telling her. HMO #2 says they can't/won't pay for it because it was done over 1 year ago. Now, the surgery center is demanding the payment for the surgery.

She does not have thousands of dollars to give to the surgery center in 30 days and I'm really needing advice on who to talk to because this does not seem right.

So, here are my questions:

1. Is it legal for an insurance to approve and pay for something, then retroactively deny it a year later without notifying her?

2. What agencies should we be contacting? What kind of lawyer or resources should we be looking into? We are located in southern California.

3. How do we approach the surgeons office and their demand for full payment in 30 days? Is there a way to either extend the time or put a hold on things while we figure this out? Should we ask for a payment plan and then go after the HMO for repayment at a later date?

4. When she signed the agreement with HMO and surgeons office,, it said that should the insurance deny it, she would be liable for the full payment of the procedure. Because the insurance did approve and pay for the surgery, did this legal waiver make her liable due to the retroactive denial?

Any guidance would seriously be so helpful right now. We just don't know how this could happen or be legal.