WTF? Insurance company denies claim, saying it was "pre-existing"...

[LiberalHeart]

The patient: a pre-teen kid (my grandson) with a problem probably present since birth, but symptom-free until recently so it was never diagnosed. Now there's a hospital bill for thousands of dollars the insurance company is refusing to pay, saying the condition was pre-existing. But how can someone inform the company of a condition if they don't know it exists?

Anybody ever face this problem? And if so, were you able to fight the insurance company successfully?

The insurance is something his mom has through her work; group policy. She said when her employer switched to this company there was form to fill out and she was asked if anyone in the family had a condition for which they received on-going care. She truthfully answered no.

The kid has to have surgery and if this decision holds, there'll be no way to pay for it.

[madeline_con]

1. Contact John Edwards. n/t

[Radio_Lady]

6. Edward is too busy. Contact Elizabeth Edwards or... maybe some lawyer in your own city.

Good luck... this country is so f***ed in so many ways, it makes me sick.

[Hekate]

27. Elizabeth Edwards is busy running the campaign. Lawyer in your own town would be better. nt

[Radio_Lady]

43. Upon contemplation under painkillers, I agree with you, Hekate.

Explanation in case anyone gives a sh** --

Molar tooth endodontically treated on 9/5/07
Painful for several weeks.
Endodontist took out gutta percha and put in calming medication (calcium hydrochloride) and left for a while which made it feel a bit better
Next step "final filling" November 07

More pain on and off throughout December.
Three consults later with three different dental specialists -- original endo guy, perio guy, second endo guy.
Original endo guy plans to put in more calcium hydrochloride on 01/22/07
Everybody thinks the tooth has a fracture and won't survive. I'm exhausted and willing to do anything at this point. Meanwhile, I try to live each hour.

[Hekate]

58. aaaaaaagggghhhh dental work. Best of luck with that.

:-( get some rest. Hopefully DU will be more or less restful tonight.

Hekate

[bemildred]

2. Sue. nt

[Kittycat]

3. They have to appeal, and also get their benefits manager involved.

Also, since it's employer based, and he was never treated for this in the past. A letter from the dr, stating this as fact should take care of it. *should*

[Radio_Lady]

11. Employer benefits manager might help, but remember...

the employer (and its benefits manager) may not want to cross the insurance company.

This happened with me on an employment issue in 1992. Human Resources manager was *supposed* to be my advocate; turned out she was just another arm of management who turned my story against me in a Reduction in Force issue.

[Kittycat]

34. Well, it's the only way we've gotten some of our son's issues addressed.

Granted we use it as a last resort. But in this case, since there was a specific letter of disclosure in question - it's best to get benefits involved. If they messed up somehow - they'll act in the patient's benefit to protect their ass from a lawsuit.

If the OP reads this, can I ask the name of the insurance company, and if you know whether it's a national company or not?

[rodeodance]

48. so many company benefit managers exist to help the employER keep the bottom line!!

[Diane R]

4. We've faced it plenty of times.

My oldest son had chronic asthma, allergy, sinus, etc. problems that often necessitated hospital stays. The insurance company claimed they wouldn't pay for his 'pre-existing condition'...and we had to pay out of pocket. A month before the three year waiting period was up, they would cancel out insurance and we had to start all over again (the fine print allows them to do this without cause). This happened three times.

I appealed to our insurance commissioner, and he (of course) found no wrong doing. I later found out he was a former insurance executive.

[flordehinojos]

13. former insurance commissioner ??? that sounds like bill nelson of fla, but he is now a u.s. senator

wearing a democrat's cloak.

[katty]

5. unfortunately this happens quite a lot - see: SICKO and other

articles

[NoBorders]

7. Go after them big-time. They just say this shit automatically

They hope to scare people off with the first brush. Hire a lawyer if you have to, IMHO.

[Junkdrawer]

15. Good advice. Back in 1994, my insurance company rejected EVERY...

bill from my wife's pregnancy.

I appealed every one and they paid every one.

[road2000]

16. This is true...

And it came to me straight from the mouth of a corporate lawyer for a health insurance company. They frequently refuse large claims on the first go-round. You may need to have your lawyer write the provider a threatening letter.

Good luck to you.

[NoBorders]

33. And my current client is a giant insurance company

I'm in IT consulting, so I have no say on policy, but I've sat in on plenty of meetings with the lawyers.

It's not all as cut and dried as it might seem on the surface.

[prairie populist]

42. Bingo - I have a cousin in administration

at M of O and this a matter of business practice there.

[elehhhhna]

8. If it's a large employer, they need to be brought into this --

it's amazing how fast the ins co responds when the folks who pay the premiums complain. Also contact your state board of insurance. ASAP

[MadHound]

9. Contact your state insurance board, your state attorney general, and hire a lawyer.

This is bogus bullshit, and most likely the insurance company will back down if you land on them with both feet.

[Journeyman]

10. My 1-year-old daughter had surgery for a congenital condition . . .

everything went according to plan and with the insurance company's approval, but when the bills were presented we were denied because it was "a pre-existing condition."

WTF?

Many messages, many snarky comments ("I was unaware we could only give birth to healthy children"), and months of persistent badgering, I finally got a lawyer to help me get what I thought we'd paid for all those many years.

The lawyer was my brother so I wasn't out anything for his services. But I think many claims are denied routinely, in hopes you'll just go away and pay it yourself, so it's definitely worth looking into. If nothing else, write a few letters yourself. It can't hurt to try.

Single payer universal coverage. Womb to tomb. It's the only sensible approach.

[debbierlus]

31. Horrendous, isn't it?

Preexisting conditions should NOT be allowed. Period.

[XOKCowboy]

12. I'd say get a lawyer quickly

The insurance company expects you to roll over as most people do. Get a lawyer who specializes in insurance matters and fight this.

Good Luck. I hope that your grandson will be OK.

[juajen]

25. When this happened to me, I could not afford a lawyer,

and, they wouldn't take the case on a contingency basis. I was stuck. We eventually had to declare bankruptcy because of this 60,000 dollar hospital bill. This amount did not include the doctor's charges or lab fees. Just the hospital. For a while I thought the hospital was going to sue on my behalf; but, no such luck. I was told by the lawyers I contacted that insurance companies do this all the time; but they they won in court or settlement at least half the time; hence, no contingency fee. They wanted 5,000 dollars up front to take the case. I hate the health care business in this country.

[Radio_Lady]

14. LiberalHeart, was this condition EVER noted on your grandson's health records?

At birth -- early schooling -- somewhere?

I don't think the insurance company would know about it UNLESS they got it from SOMEWHERE.

Can you access his medical chart/birth records?

[LiberalHeart]

18. As far as we know, it was never noted -- but it is something supposedly checked at birth.

If it was noted, no one told my daughter. I also know he never saw a doctor for the problem till recently when it was treated as an emergency. I don't have access to his medical records, but maybe she does. I do know that a specialist recently said it may or may not have been present at birth; he didn't know for absolute sure. When he said that, he mentioned that babies are checked at birth which is the only way I know that babies are supposed to be checked.

[TwilightZone]

17. Assuming that his mother has discussed this with them, what was their excuse?

Unless there are specific exemptions listed within the policy itself, I'm not sure how they could deny it as a pre-existing condition unless it was documented somewhere in his medical records.

[LiberalHeart]

19. They didn't offer an excuse. They said they asked for additional info....

...from the providers and didn't get it. But the providers said they sent the info that was requested.

[TwilightZone]

21. Ah, the paperwork game.

They might - and I stress "might" - be denying the claim until they receive documentation that indicates that it wasn't pre-existing.

Maybe his mother can request another copy of the documentation from the providers and send it certified mail. The insurance company would have a more difficult time claiming they didn't receive it if a paper trail existed.

[smoogatz]

20. They pay people to reject claims for whatever bullshit reason, hoping

you'll give up and go away. It works for them—lots of people do just that. Call the person who denied the claim and ask to speak to his/her supervisor. Have their pre-existing conditions policy in your hand: usually these stipulate not just the existence of the condition, but prior treatment of the condition within a specific time period: usually six months to a year. If your grandson wasn't treated within the stipulated time period, they have no grounds to deny the claim.. I'm not aware of any insurance policy that allows denial of a genetic pre-existing condition that surfaces in adolescence or adulthood: in that basis they could deny almost any claim for treatment of any disease that has a genetic link. It's bullshit, and they know it. Go get 'em!

[Lydia Leftcoast]

22. A couple of years ago, there was an article in the New York Times

(I wish I'd kept the link) in which a health insurance executive ADMITTED that his company routinely denied any large claim in the hope that the customer or doctor would give up and not pursue it.

Submit the claim again, and also alert your state insurance commissioner, your state legislator, a local newspaper columnist who is likely to be sympathetic, anyone who might have any influence.

[PA Democrat]

37. Here are a few interesting articles on a company that pulled this crap on me.

They look for the flimsiest rationale to say you have a preexisting condition, often citing past symptoms that have NOTHING to do with the condition they are saying is preexisting.

I fought this same company and won. I filed an appeal with the company along with a copy of the complaint that I filed with my state's insurance commissioner. My complaint included copies of the articles below citing their past corrupt business practices. They paid up within less than a week of receipt of my letter.

But what really infuriates me is that they have not had their license revoked or been put out of business. They continue to screw more people because they get away with it usually with nothing more than a slap on the wrist.

http://www.usatoday.com/printedition/news/20070129/1a_cover29.art.htm

http://www.cbsnews.com/stories/2007/05/24/cbsnews_investigates/main2850054.shtml

http://www.medicalnewstoday.com/articles/72261.php

[Warpy]

23. If the problem had never been diagnosed previously

you should be able to fight them successfully. If any physician in any note anywhere had ever mentioned the possibility, you're out of luck, even if he neglected to do the proper diagnostic tests.

Saying a congenital condition is a pre existing condition doesn't quite fit the bill of what a defined pre existing condition is.

These bastards are getting really nasty, aren't they? Time to vote for Edwards. At least he'll allow us to opt out of for profit insurance and opt into Medicare.

[madmom]

24. Clear back in 1984 my father-in-law had a heart attack, everything came out ok, but when

it came time to renew his CAR insurance they rejected him because of this. They said if he got his car fitted with a device.... When asked what kind of device that you could fit on your car, warned of an up coming heart attack we heard nothing. They still refused his renewal.

[Hekate]

26. Often, they reject automatically. Appeal immediately & keep appealing. Keep a phone log.

Keep a phone log of every person you talk to and a file of letters. Get the employer involved through the Personnel/Human Resources department.

Oh, and start appealing to the hospital immediately. There are some very scary stories out there about hospitals that have charitable funds and charitable foundations but who essentially refuse to access them for actual patients. See if there is any help from that direction. It may or may not help, but if you don't ask you don't get.

That's all I can think of to add to the good suggestions already here.

:hug:

Hekate

[gateley]

28. Contact a local TV News show that has some kind of "consumer complaint"

department. They often air the situation, and contact the wrongdoers. The companies often will change their minds in the light of negative publicity.

[debbierlus]

29. Don't panic yet. Insurance companies often deny claims the first time out

It is despicable, yes. However, often the first appeal will get you coverage. They automatically decline WHATEVER they can because a certain percentage of people won't challenge it.

I would recommend a call to the insurance agent assigned to the claim, & inform them that you are very progressively active & you will be blogging & posting the course of this situation. Tell them you are going to call your Congressional rep, & that you will be writing to the editors of your paper & contacting media sources. They won't want to deal with the possible fall out. If they ignore you & continue to deny the claim, follow through.....

Be the squeaky wheel. I am very sorry you have to deal with this, it is an all too common experience.

Fight back.

[malaise]

30. Sue then if they were collecting premiums from you n/t

[postulater]

32. Challenge them fast and hard.

Get your doctor involved.

You WILL win this one.

[Dorian Gray]

35. My friend's entire birth process

was denied by her insurance provider once. They fought it, and the company that her husband worked for threatened to cancel them as their insurance provider if they didn't pay for it. (They employed over 100 people and that would be a huge hit to the insurance company.) So, the company caved. If her mom can go to the company and have them back her up, they may have a chance.

[Vinca]

36. Publicity, publicity, publicity.

Nothing makes an insurance company cave faster than bad publicity.

[Liberal In Texas]

38. I want to see universal national health care If for no other reason than to see these scum bags

go out of business.

[judaspriestess]

39. I'm sorta in the same situation

They are reviewing if my ailment at the time was pre-existing. So I'm a couple of weeks away from being to sent to collections (which will eff my credit) because the insurance company is mulling it over. Thats the other part that is disastrous about our current healthcare system. Hospitals, doctors, etc just send you to collections at the drop of a hat affecting your credit.

WTF is good to have insurance if they don't pay for anything. Its ridiculous.

[aint_no_life_nowhere]

40. Insurance companies deny claims even for non-preexisting conditions

My cousin developed a heart condition from the stress of years working in a hectic law office. He had insurance but they refused to approve his treatment and refused to authorize an EKG that would have helped diagnose the problem. He had to go to Mexico to see a very highly trained European-educated heart specialist. He received excellent treatment, an EKG and several other tests and obtained very inexpensive pharmaceuticals to treat it. It probably saved his life. If you do some careful homework, you can find very well-qualified doctors in Mexico at a fraction of the cost of the U.S. In your case, I'm sorry to see that it's too late and you already have a mountain of bills.

[WillowTree]

41. Did he receive any diagnosis and/or treatment

for the condition in question (or one that would be closely related) before the coverage went into effect? ANY treatment at all, including taking any medication? Or did he have any symptoms at all before that time? If so, how long before?

And how long after the new coverage went into effect was his first treatment?

And, unless you'd really prefer not to say, what condition is it that we're talking about here?

[LiberalHeart]

53. No, no treatment at all. Here's what happened....

He started having a lot of pain in the middle of the night and was taken to the ER, and that's what these bills were from -- plus for testing that followed. And follow up treatment by the primary care doc and some specialists. They found no cause for the pain at the ER, but later a doctor looking at the images taken at that ER notified his regular doc that there was a problem with one testicle. It was up inside him and subjected to heat which caused the pain, which in turn can lead to cancer. But further testing showed that the condition changes -- sometimes the testicle is undescended, sometimes not. Thus the pain is sometimes present but not always. He had some tests for some other conditions that apparently can present the same or similar symptoms. They the condition can resolve on its own with age, but if not he'll need surgery and it sounds like surgery is what's recommended. He has had several MRI tests and one invasive test as well as lab work. It's really adding up.

My daughter tried to talk to Human Resources at her job but the person in charge was out today. They're off Monday. She won't know till Tuesday what the employer's response to this will be.

[midnight]

44. Can you find the ear of a Senator that seats on a Committe of

Health and or Insurance? Call someone in your daughter's State legislature and start asking around. Hopefully it's a Democrate. Then explain your situation and have them overide the Insurance Co. decision. There has got to be someone running for office in your daughters area that would take this on. This is over the top crap.

[leftofthedial]

45. whatever you do,

don't go to Hillary or Obama for help. They're on the insurance company's side.

[rodeodance]

46. If not diagnosed till now--seems to me they can fight it.

[upi402]

47. You're right, it happens to virtually everyone

who has had a health problem. I've used hospitals in 3rd world countries and they kick our medically insured butts.

[1monster]

49. Prot est it in writing. Tell them they need to prove that you knew of the

condition prior to getting their insurance coverage... Doctor reports, hospital reports, any previous medical treatment for the condition, etc.

If they cannot, they must pay.

Also, make sure you let them know that YOU KNOW that if you take them to court for this, and you win, they will be paying mucho mucho grande more than the current medical bills, i.e.: your legal fees, all the medical bills, time lost from your job pursuing this, for your credit score loss because they did not live up to their obligations, punitive damages for failure honor their contract with you, and for failure to show good faith.

(There was a case in the city I live in where a national insurance company refused to pay any of the medical bills for a young girl seriously and permanently injured when the insured ran over her. The parents of the girl sued the insured and the insurance company and won. The insurance company's original liability was $50,000. With punitive and other damages, the insurance company, finally ended up paying out $17,000,000 to the parents of the girl. Failure to show good faith was a big part of that settlement. They could have ended up paying even more, but finally settled when things were looking really bleak for the insurance company.

[OzarkDem]

51. Agree

never just accept what they say, make them review the decision again and defend it.

[OzarkDem]

50. Contact your state's agency that regulates insurance

Here's ours in Ohio

http://www.ohioinsurance.gov/

Your daughter should file an appeal and ask them to reconsider. If they still say no, then file a complaint with the Dept of Insurance.

Either way, he should go ahead and have the surgery and work through the appeals process to make them pay for it.

[no name no slogan]

54. Call the state Attorney General's office

nt

[Imagevision]

52. Bonuses are given to those denying the most claims quarterly in the Ins. biz

as was depicted in Michael Moore's sICKO movie.

[ProudDad]

55. Contact Michael Moore!!!

He's the most likely to do something!


http://www.michaelmoore.com/

[ThoughtCriminal]

56. Yes, this happened to us - and they eventually paid

This was in the early 90's - before HIPAA placed restrictions on group insurance exclusions. We had continuous group coverage, but in those days they could still exclude new policies for some period of time.

Our son had a sizable lump on his neck. Fortunately, the biopsy was negative.

The insurance company claimed that since our son had strep-throat the previous year, it was a pre-existing condition and refused payment for the hospital, doctors, lab work, etc. We obtained letters from every doctor that examined him dismissing the insurance companies claim. They still would not budge. What finally seemed to work was the threat of a lawsuit from my employer. They paid, but we had to go rather deeply into debt for a while to keep collections off our back.

If this REALLY is Group Insurance, you should be aware of HIPAA:

Title I prohibits any group health plan from creating eligibility rules or assessing premiums for individuals in the plan based on health status, medical history, genetic information, or disability.<1> This does not apply to private individual insurance.

Title I also limits restrictions that a group health plan can place on benefits for preexisting conditions. Group health plans may refuse to provide benefits relating to preexisting conditions for a period of 12 months after enrollment in the plan or 18 months in the case of late enrollment.<2> However, individuals may reduce this exclusion period if they had health insurance prior to enrolling in the plan. Title I allows individuals to reduce the exclusion period by the amount of time that they had “creditable coverage” prior to enrolling in the plan and after any “significant breaks” in coverage.<3> “Creditable coverage” is defined quite broadly and includes nearly all group and individual health plans, Medicare, and Medicaid.<4> A “significant break” in coverage is defined as any 63 day period without any creditable coverage.<5>

http://en.wikipedia.org/wiki/Health_Insurance_Portability_and_Accountability_Act
http://www.hhs.gov/ocr/hipaa/

[yellowdogintexas]

57. if it is a self funded plan, they can make up their own rules about a lot of thing

carefully read the pre ex clause in the policy.
different states have different rules.
how long has the policy been in force?
if he has been covered under this group continuously for a long time with reg med care etc and no mention of this then they should have asses kicked into week after next

they may be using pre ex when they really mean congenital.