When the Health Insurance Companies give you the Runaround with a Claim
A yoga instructor in Northern California thought things couldn't get worse when she was told she needed to surgery, for a painful growth she had on her hip bone. It would take her time to recover , and get back to her class; her salary would suffer and so would her home life. But at least, she thought she was covered for the expensive surgery, as she had a plan with one of the best health insurance companies in California. Her doctor told her that he had performed this very kind of surgery on several other insurance-covered patients over the past couple of years, and claiming had never been a problem. The surgery went well, and just as she was getting back on her feet, she received a bill in the mail. It was from her hospital; for about $25,000. Her insurance claim had been denied.
About 10% of all claims placed before health insurance companies in America, get denied. It is no surprise. Her bill, informed her that she had the option to appeal against the decision. And that is exactly what she did. She read up in medical periodicals and elsewhere, to find reports that the procedure worked really well, and it wasn't experimental at all, as her insurance company claimed. She put all that in letter, included a letter from her surgeon who said the same thing, and filed it. Her appeal was still turned down as most health insurance companies will do. She then took her appeal to her health insurance company's external review board, where a third-party doctor looked at her case. The expert said that while it would be hard to convince the company that her surgery was indeed medically "recognized" and not experimental, she had a strong point in her argument that the company had found no such problem, allowing the surgery for other people that same year, as her surgeon told her. And she won.
But the insurer, right after conceding the case, went and protected itself from future claims, by declaring that surgeries of this kind would not be covered from then onwards. The woman in this case had a hard time because her insurance company tried to make a technical point, about whether the procedure in question was a valid one. Health insurance companies often give their subscribers a hard time, if they are forced to visit the emergency room at a hospital that is not covered under their insurer's network. If they have a condition that requires the doctor to try several kinds of medicines, before he hits upon the right one, the insurance company will have every excuse to scream "Experimental!". But lots of cases get denied for far simpler reasons, like clerical mistakes in how your hospital or doctor filled the form. Appealing, always make sense. Half of all those who appeal, win.
However, if you are planning action, make sure you do it before the deadline is up. With health insurance companies, it's usually between two and three months. Just make sure that your appeal is properly drafted. You don't want to give them an excuse to throw your case out, do you?
A yoga instructor in Northern California thought things couldn't get worse when she was told she needed to surgery, for a painful growth she had on her hip bone. It would take her time to recover , and get back to her class; her salary would suffer and so would her home life. But at least, she thought she was covered for the expensive surgery, as she had a plan with one of the best health insurance companies in California. Her doctor told her that he had performed this very kind of surgery on several other insurance-covered patients over the past couple of years, and claiming had never been a problem. The surgery went well, and just as she was getting back on her feet, she received a bill in the mail. It was from her hospital; for about $25,000. Her insurance claim had been denied.
About 10% of all claims placed before health insurance companies in America, get denied. It is no surprise. Her bill, informed her that she had the option to appeal against the decision. And that is exactly what she did. She read up in medical periodicals and elsewhere, to find reports that the procedure worked really well, and it wasn't experimental at all, as her insurance company claimed. She put all that in letter, included a letter from her surgeon who said the same thing, and filed it. Her appeal was still turned down as most health insurance companies will do. She then took her appeal to her health insurance company's external review board, where a third-party doctor looked at her case. The expert said that while it would be hard to convince the company that her surgery was indeed medically "recognized" and not experimental, she had a strong point in her argument that the company had found no such problem, allowing the surgery for other people that same year, as her surgeon told her. And she won.
But the insurer, right after conceding the case, went and protected itself from future claims, by declaring that surgeries of this kind would not be covered from then onwards. The woman in this case had a hard time because her insurance company tried to make a technical point, about whether the procedure in question was a valid one. Health insurance companies often give their subscribers a hard time, if they are forced to visit the emergency room at a hospital that is not covered under their insurer's network. If they have a condition that requires the doctor to try several kinds of medicines, before he hits upon the right one, the insurance company will have every excuse to scream "Experimental!". But lots of cases get denied for far simpler reasons, like clerical mistakes in how your hospital or doctor filled the form. Appealing, always make sense. Half of all those who appeal, win.
However, if you are planning action, make sure you do it before the deadline is up. With health insurance companies, it's usually between two and three months. Just make sure that your appeal is properly drafted. You don't want to give them an excuse to throw your case out, do you?