My Isurance cmpany denies claim as was transferred from emergency room to inpatient for surgery. Can they doit

Question

I am under a corporate plan with Atena. The plan says 100% coverage of emergency room services with 100 copay and 80% if admitted to hospital. My wife was admitted in emergency condition in ER. She was diagnosed having an abscess and had t be operated in normal OT for which she was admitted as inpatientas her condition was very critical. Now the Insurance company is saying that the expense of OT and admission is not covered under emergecy room but as inpatient and 20% ha to be borne by us. Is this admission is not incidental to admittance in ER becaue the kind of operation was not possible in ER and that's why she was admitted as inpatient. IS Insurance company correct in denying 100% coverage? How do i deal with them.

Answer 1

Well, I wouldn't complain about 80% coverage. If you really want to take the time you can certainly look into it further, but I would think you would be happy where you stand. Write a letter to the company and they will respond.

Answer 2

Check your fine print very carefully and it there is any grey area at all, as your question suggests, phone your broker.

Then move up the ladder, writing letters, emailing and faxing as you cover every step.

Your point is this- you invested in this insurance company, you relied on their reputation and fine standing, and you trusted that when they promised the coverage they would make good that promise.

This is plain deciet, and is the trend of insurance companies who are out to make profits, billions of dollars a year...

Insurance companies have a mandate and it is not to settle with customers, it is to reduce the pay out as much as possible.

The largest company is AVEVA [I might have spelt the name wrong}and they own many smaller companies, so if you are under one of their front companies be warned, they will do anything and everything to argue every dime of pay-out.

It might be worthwhile taking the time to find out who actually owns the company, so if you ever shop for insurance in the future, you know who you are dealing with.

All insurance companies are not the same. The bottom line is profit, not to make claims easy for the trusting customer.

Answer 3

Yes, according to how you say the contract is worded.

That's how the insurance companies get you.

Your company needs to find a better plan that costs no more then
the old plan but has better coverage. Lots of luck with that.

MERRY CHRISTMAS and have a nice day.

Thank you very much, while you're up!!!!!!

Answer 4

Let me get this straight. You're complaining because your policy pays for exactly what it says it does? Everybody should have it so rough! The insurer should pay 100% for the treatment required to stabilize her for surgery, but the inpatient part is as you state. That's the way hospital care works.