Health Insurance company refusing to pay bills. Claim it is pre-existing...?

Question

My insurance provider is refusing to pay my medical bills from surgery I had last August. They claim it was pre-existing however a review of my medical records will show that this is / was not pre-existing. Do I sue the insurance company or does anyone have any suggestions? The total amount of the bills owed are around $2000 not to mention the derrogatory effect the outstanding bills are having on my credit. I don't have an extra $2000 laying around to pay them all. I would owe nothing if the insurance company would do their part. I have paid all my co-payments. Anyone have a fantastic suggestion to rid myself of this burden once and for all. I have had about..no kidding...30 phone calls with the insurance provider to no avail.

My $3000 deductible was met at the time of the surgery. Without giving too much detail, the surgery was "female" related and stemmed from my annual exam. I have NEVER had any issues in the area before. I can get records as far back as 10 years and there will still be nothing related to the surgery that I had last August. Appeals process was started months ago and quite frankly, I am tired of waiting on them to only give me excuses or to tell me "these things take time" I'm certain it doesn't take a year to look through 12 months of medical records that equal about 100 pages as I never go to the Dr.

likehown: NO there isn't anything in my records at all related to the surgery I had. They only asked for 12 months of records which I provided right away, my policy states that preexisting condition found in the prior twelve months will not be covered. A simple pap smear is only performed once every year. Once they denied my claim, I went a step forward and provided several years of records to show there have never been any claims as it relates to the ob/gyn. and as far as your comment of they "don't make these thigns up" I am 110% positive that they do ANYTHING they can do to receive your premium payment and not dish anything out.

ONE MORE TIME PEOPLE: I have NEVER so much as had an issue at all as it relates to the surgery I had. This was a first time thing that unfortunately required surgery to correct.

Answer 1

Phone calls mean squat, as you've found out. You need to appeal the denial IN WRITING. It might be too late, as now the bills are over a year old, but it's your second best shot. AFter the denial is re-denied IN WRITING, back to you, you take that denial, the copy of the original letter, and write to the state insurance department of your state, telling them this is NOT pre-existing, and sending them copies of your appeal letter and the denial.

They will intercede.

Answer 2

First of all, you need to go the Insurance Comp grievance and appeals department for help. You will need all medical records from the time around your surgery, before and after, from what the doctor had found and why you needed the surgery. They will request it for proof that the condition was not pre-existing. Read your insurance policy/terms-Conditions of what is included/excluded. Also, do you have a co-insurance or deductible amount that you have to pay, in your policy? Even if you've paid your copay's, you will have to pay them. Sounds like the $2000 might be just that.

I have worked for insurance companies for the last 3 years and have learned alot. You really need to read everything in your policy and understand your coverage prior to having any procedures done. I will call my company Customer Service (if you don't understand everything in your policy) and ask what will and will not be covered prior to having something like that done, so I will not be surprised when the bill comes.

If anything, see if the Human Resource/Insurance people at your work can help you in anyway. Maybe they can talk to the Insurance company for you if you give them permission too, they are used to working with the Insurance people....

I wish you a lot of luck.

Answer 3

I haven't read the other responses, but here are my thoughts:

If you haven't filed a formal, written appeal with your insurance company, do so now.

Next, file a complaint with your state insurance commissioner.

Third, get your doctor involved if he has not been involved on your behalf already. He should be able to write a letter to your insurance company (this can be included with your appeal), stating when he first treated you for this condition, and also verifying that it was not a pre-existing condition.

When you call the insurance company, ask to speak to a supervisor. Don't just talk to whoever happens to pick up the phone. You're probably talking to customer service, not even the people who are actually processing your claims. Customer service gets all their information second-hand. You need to be speaking with someone who knows exactly what is going on with your claims, and someone who can help you resolve the issue. Get the name of the person you speak to, and call that person everyday until you get resolution. If you have to, go to that person's supervisor. Just keep working your way up the ladder until you get to the top.

I wouldn't make threats if I were you. There's an old saying that you'll catch more flies with honey than with vinegar, and it's true. People will be much more eager to work with you if you're kind, no matter how frustrated you are.

I think you're wrong when you say that insurance companies want to collect your premiums but not pay your claim. The truth is, there's a lot of red tape. A lot of claims processors are relatively uneducated, and they see only in black and white. They do everything "by the book", even when the situation requires something a little different. These are the same people who, when they take my order in a fast food place and I end the order by saying "and that's all", they immediately ask, "do you want fries with that?" They don't really listen to YOU - they just do what the training class programmed them to do, and they don't know how to customize it to individual people.

Good luck. I hope you're able to get this resolved.

Answer 4

Lets break down the issues:

Credit - If you are taken to collection, simply document what you mentioned above, and send the collection agency copies of all documentation - this will help protect your credit.

Insurance - Your agent or HR department at your company needs to get involved. They will have contacts other than the people at the customer service department. Put some heat on these folks from every direction

Another option is to file complaints with your states department of insurance, the better business bureau, and better yet, copy employess of the insurance company on the email....If possible, go to the insurance companies website, and see if you can figure out the CEO's email address, and copy them on your complaints.

Bottom line, do not pay a lawyer, do not pay the $2000 with hopes of them reimbursing you.

Calling them 30 more times will not help you. The front line people are not emplowered...Let the painfully slow process work itself out....And use the above methods to move it along and protect your credit rating....

Answer 5

Make arrangements to pay $5 or $10 a month with the Doctor. Tell the the Dr.s office you are working with the insurance company so that they do their part.

This way you are trying to make good on the debt.

Then, I know 30 phone calls don't seem to be enough...but a letter, more calls and a lawyer might have to be the next steps.

Good luck, I have been there...and my bill was over 1 million!

Answer 6

We all have a "pre-existing condition" and are currently dying of it right now: AGING. In any case, I do not doubt that people do get denied for health insurance based on a "PEC" the same way as a driver gets denied for car insurance because of a bad record. Perhaps what they need is MEDICAL COVERAGE which is readily available to them from the public if not private sector. There are always alternatives... But then I suspect this term is as exploited as the "thousands dying in the streets without health coverage" and yet... there are no bodies.

Answer 7

First of all, ask the insurance company for its dispute policies and procedures in writing. If it doesn't look like you will be able to appeal the decision without help, find an attorney...many will take a case like this on a contingency fee basis, meaning that there will be no fee unless they recover for you (usually through a settlement). Make sure you are aware of any non-attorney's-fee costs that may be involved before you go too far, as research, expert opinions, etc, which all cost money. Good luck!

Answer 8

As long as you can document every step you've taken with the appeal, and it looks like you can, file a complaint with your state's insurance board. Have the doctor's office do the same, if possible. The insurance board is bound to investigate the complaint. I've gone to my local state Congressman for help -since my state senator (who's too busy running for President, the dumb b*tch) was useless. You can also email your state's attorney general - they might be able to help you - or point you in a direction to someone else who can help.

Or, you can do what I once did - I completely lost my cool on a rep after nine days of runarounds and demanded to speak to the medical director. When she gave me the line that he was in private practice, and speaking to him was impossible, I told her that most of them were in private practice, and dropped the name of another medical director to a competing plan that my boss was friends with. Long story short, I told them that if I didn't speak to the medical director by the close of business that day, I was going to file the biggest f-in lawsuit they've ever seen - that generations from now would still be paying my family. He called me within the hour, and personally pulled the claim and my appeal was answered within 24 hours. This only works on small plans. I do not recommend it on a plan like Aetna or Blue Cross/Blue Shield because they don't care - unless you happen to speak to the person holding the clue and the care that day.

Your absolute last resort will be to sue them. It won't be easy, and it won't be cheap, so make it your last choice.

Good luck!

Answer 9

You definately need to appeal their decision. On the back of your EOB statement it should state the method of how you appeal a decision they make. Most appeals are time sensitive so make sure to do this quickly. You must put this in writing as to why their decision is incorrect. You should also send your appeal by certified mail so you have a return card showing the name of who signed for it and the date received so you can prove it was sent. Good Luck!

Answer 10

You need to contact the Insurance Commissioner/Department in your state and file a complaint with them. You should also read over the right to appeal section in your policy and follow carefully the instructions there. At this point it is past time for phone calls, you need to start putting everything in writing. If after you try these two methods, you still have no satisfaction, please consider seeking legal counsel.

Good Luck!