Fighting with my health insurance provider

[gkainz]

Does anyone have any insider info on how to wage war with a recalcitrant health insurance provider? I'm in my first year with these &#$*#@& people, and they're protesting, fighting, reviewing absolutely everything. Surgery last fall was just recently denied payment after 4 months of jerking me around. They're claiming it as a "preexisting condition". Letter from the attending doc of the so-called preexisting condition and the doc performing surgery both dispute their findings. Now they're trying to amend the policy to exclude coverage for me completely, saying I was instructed to have further diagnostic testing that I did not do, prior to application for this coverage. Again, not true, but waiting for the copies of the records that they claim support their position. They had no problem cashing my premium checks for the past 6 months, however! ARGHHH!!!!

 

[bbchien]

They're claiming it as a "preexisting condition". Letter from the attending doc of the so-called preexisting condition and the doc performing surgery both dispute their findings. Now they're trying to amend the policy to exclude coverage for me completely, saying I was instructed to have further diagnostic testing that I did not do, prior to application for this coverage.

The state commissioner of insurance gets copies of all correspondence. That usually helps. In Illinois my receptionist has all the fax numbers....nothing like a little warmth to cook the egg....

 

[gkainz]

Thanks, Doc. Preflighting the old copier and fax right now, 'cause they're gonna get a workout tonight!

 

[Let'sgoflying!]

Nothing can make me unhealthier (high blood pressure, elevated endogenous catecholamines and glucocorticoids) than trying to struggle with a health care insurer.
You have my full unmitigated sympathies. I encourage you to let them know you plan to remove the gloves and fight out of the principle, to the bitter end even if it means you lose your shirt. Pay a lawyer to write a few letters, it won't cost much if you find the right one. Nothing like attorney letterhead to get some attention. Blitz their oversight agency, Bruce mentioned it. Record date time and names & offices, with extensions for everyone you talk to. Save all correspondence including the postmark.

"Retroactive Underwriting". Its a recognized and ongoing fraud in this country.
Tell the name of the company to anyone and everyone, let them know you are doing this too.

Good luck, we are pulling for you Greg. You can beat the big companies, I have.

 

[Greebo]

I was going to suggest the State Insurance Commissioner as well - but Dr. B Beat me to it.

 

[woodstock]

and even when they say uncle, don't give up.

#$%^&* insurance companies.

 

[SCCutler]

Greg:

First off, I endorse the advice to get the state's insurance officials involved as much as necessary. And, I cannot emphsize how important it is to actually understand what your state's laws say about the coverage issues you have described. Some health insurance carriers will make coverage decisions under standards which are not applicable in that state, but unless challeneged, they win. It is amazing how many people just accept a bad result without questioning it, when basic research and review would save the day.

Personal experience: My wife turned up pregnant about four or five weeks after her company enrolled in a new health plan. Routine stuff, rocked along with standard visits, prenatal care, no problem, insurer paid like a slot machine... until... that one o'clock a.m. panicked drive to the hospital after her water started leaking (she had approximately 11 weeks until due date), managed not to deliver that night, but she ended up a guest of the hospital in the high-risk pregnancy wing, "until she delivers." That was fun.

She managed not to deliver for a full minth, then the boy said, "I'm a comin'," and the focus shifted from the pregnancy wing to the neonatal intensive care unit, where Tomster spent three weeks (really special people there, by the way). Ennyhoo, Celia's first day home, we just came from seeing the pea-picker and hearing a very marginal prognosis, and in the mailbox at the house was a stack of envelopes from the carrier about two inches thick. One each for every claim that they had paid for during the pregnancy, every ultrasound, every office visit, every little thing (at that point, about $18,000.00 worth, not including the $30,000.00 or so not yet paid-for), each one witha letter stating that "...after review, we have determined that the condition for which this treatment was made was a pre-existing condition. Please remit (dollar sum) in the enclosed, postage-paid envelope." Yeah, right.

Turns out that, in Texas, a condition is not "pre-existing" unless it has been diagnosed or treated for by a physician. They still did not want to admit it, and I had to pull the "I'm a lawyer" card to get their attention. They sent a letter saying that they'd cover it as a "one time only, non precedent setting exception..." which was fine, since Celia intended to birth that particular kid only once.

Irony is, all that NICU stuff was covered no questions asked, under my insurance (same carrier, different policy). they probably dished $100,000.00 for that neonatal care.

Tommy's tenth birthday was Friday, by the way, and he's great. But (as usual) I digress.

Point is, enlighten yourself as to the applicable law and standards, contact the state's dept of insurance (whatever they may be called) and see what assistance they can offer. They may have an "ombudsman" or advocate for your assistance. Colorado is a populous state, no carrier wants to be preclude from writing there if they canavoid it.

Keep us posted. And don't give up. That is what they want you to do.

 

[wsuffa]

"Retroactive Underwriting". Its a recognized and ongoing fraud in this country.
Tell the name of the company to anyone and everyone, let them know you are doing this too.

If fraud really is suspected, then the State Attorney General will also be interested. Especially the New York State Attorney General (Mr. Spitzer).....

 

[astanley]

Greg,

Excellent responses so far. I just recently fled a very large insurance company in the New England area, and there are some key points, some of which are redundant.

+ Keep your state DOI in the loop. Depending on the state (for example, in MA, getting the DOI involved is like bringing an armed bully to a playground scuffle ) this can really help you.
+ Generally speaking, they can play all sorts of games - retroactive underwriting, ILR investigations, so on - because you agreed to them when you agreed to service with the company. I imagine you self employed or work through a small group (<100 person) company?
+ Do a bit of due dillegence and research your states insurance statutes. Every state is different, some are far more consumer friendly (MA, generally, except for automotive insurance), some are not (I've heard horror stories about Texas). Make sure you have all the facts - many insurance companies will emply tactics that rely on you not knowing the law
+ Consider including the Department of Consumer Affairs, usually a part of the DA's office. This again varies from state to state.

Be forewarned: If you are self-employed / single insured, then they may drop you like a hot potato. This, unfortuneately, is the price for squeaking.

You'll need to document each part of hte process. Dates, times, doctors you saw. Stupid things like a doctor or his admin filling out a claim improperly can kill you - I bet Dr. Bruce has had this happen - things like wrong onset of illness, reason codes, wrong CPT's or ICD-9's, location codes... all these things can trigger an automatic and painful process (especially if coordination of benefits is involved - like when I screwed up my rib last year, and then reinjured it this week, I *know* my doctor will list the location of the event being my office - which will trigger a COB between my health plan and my company's workmans comp. I'm almost considering not going to the doc and seeing if the pain subsides) that you get to deal with.

Keep better records, call daily, CC everyone including God, and be prepared to fight.

(Side story: My finacee moved to MA just after we started going out. Moved with her car, bought "full" insurance. Full, in CT, means "fire / theft" and so on. In MA, it's called "Comprehensive" when they include all products. Her car was stolen and torched one day from our apartment, she calls insurance company and lo and behold, no fire / theft on the car. 2 hours later, a senior underwriter calls and informs her that "MetLife will not be paying for your car and your policy will be retroactively cancelled from this point on". Good timing buttheads)

Good luck Greg!

Cheers,

-Andrew

 

[gkainz]

Thanks to all for the hints, tips, and cheers. The battle is underway and we'll see how this turns out. I don't intend to go down without a fight - it's now the principle of the thing (ok, it's the money... $30k of denied claims and an adjustment to the policy retro to the date of inception that makes me uninsured). I'm really concerned about what this could do to getting insurance with another carrier.
I'm a small business, but this insurance is an individual policy, major medical with an HSA. Turns out that S Corps can't fund an HSA (go figure?) so I'm doing this as an individual.
Andrew, funny you mention CPT, ICD-9 and locality codes...I'm in the middle of a large project for the VA...rehosting their claims processing system and today I just migrated their CMAC, MSA and SMSA data... I'll have medical code nightmares tonight!

 

[Ghery]

I hope I don't have to go through this with my wife's insurance after her fall from the ladder 2 1/2 weeks ago. Trip to the hospital in an ambulance. Two nights in a VERY expensive hotel (hospital). CAT scan. etc. And, she was back yesterday to have it operated on (while I'm stuck on the east coast in meetings!).

BTW, if you have a similar beef witha bank, include the Comptroller of the Currency in your distribution. That office will follow up and the bank will NOT ignore you. I had a little trouble with Chase Bank a few years ago and it was resolved to my satisfaction after writing a letter and including the Comptroller on the cc list. Resolved quickly, too. This after customer no-service was snotty on the phone. Oh, and I fired the bank after the matter was cleared up.