[tumbleweed]

First, your brother should read the pertinent sections in his Certificate of Coverage (for groups) or his individual insurance policy concerning emergency care and participating providers. Sounds like both Oxford and his plan penalize for use of out of plan providers. For HMO and PPO plans it is critical to use in-plan providers. Some plans will pay less, and some will pay zero when out of plan providers are used. There are usually exceptions for emergency treatment, which the policy or Certificate define.

His plan documents should include a section on filing appeals if he believes the contractual terms were not followed. His appeal can be made directly to the Insurer within the stipulated time period. If his is an employer provided plan (many of which are self-insured) he can explore the matter with the appropriate HR benefit person and perhaps get some leverage. He can also submit a complaint to his state Insurance Commissioner, but such appeals are usually not effective unless the Insurer clearly violated contractual provisions.

Another possibility- see a lawyer who knows how health insurance works and is willing to handle. Sometimes a stiff letter from an attorney will cause re-consideration.

My question: Why did he not go to an in-plan MD for follow-up?? Unless there were extenuating circumstances, his plan is not likely to change their decision, and Oxford is likely to affirm that they provided the necessary emergency care and is not responsible for his subsequent surgery, etc.