Denial of coverage for infant surgery

[rxkht]

What is the name of your state? Tennessee

I have an infant son who is requiring ear tubes be placed in both ears due to fluid accumulation. My insurance is trying to refuse to pay for the procedure because at 2 months of age (3 months before we had coverage with this insurance) he had 1 ear infection. They are claiming that due to this one infection his condition was pre-existing prior to our date of coverage.

The infection he had was self-limiting, resolved with one course of antibiotics, and he had no other problems until he was 6 months old (a month and a half AFTER our coverage began). Since and including the infection at 6 months old, he has had fluid accumulation in his eardrum which has led to 3 additional infections and, if left untreated, could render him with hearing loss and delayed speech development.

When we applied for coverge with this insurance they did a complete medical review to determine if there were any pre-existing conditions for anyone in my family and they made no clauses for my son even though they knew about the one ear infection at that time.

Are they allowed to now claim that his condition was a pre-existing condition even though they did not classify it as such when our coverage was issued?

Can they deny him coverage for this procedure because they now say that the one ear infection was a symptom of his current condition even though it did not cause or have any bearing whatsoever on the fluid accumulation that has caused the need for this operation?

 

[rmet4nzkx]

You should be able to appeal the Insurance denial.

However, the first infection could indeed be the begining of a series of infections or very likely the infection was not completely knocked out with the first round of antibiotics. You might ask that the doctor try a different antibiotic next time, I had a similar thing happen with my son, his first infection was at 10 days and a series until 2yrs when a new doctor figured it out, changed the antibiotic and wiped out the infeciton. They also thought his ear drums were scared but he had no hearing loss when tested and no speach or learning delays. The tubes are not always successful and often come out.

 

[cmorris]

My post only has to deal with the tubes:

My sister had tubes put in multiple times (they kept coming out) and at 19 years old, she had to have hearing aids. While multiple ear infections can cause hearing loss, so can having tubes multiple times (this is common when a child gets tubes at a young age).

My son also had problems with ear infections since he was a month old, which did lead to tubes (once). However, he was about 9 months old when he had the tubes put in b/c the ear infection would not clear up. He had been on multiple antibiotics and was seen by several specialists. As of now, the tubes are out with little scar tissue. His doctor wanted to put the tubes in again, and I have yet to comply b/c his ear infections are gone.

I am assuming your child is under 6 months old. I would try another antibiotic (as suggested previously) before resorting to surgery. One ear infection (if cleared up) does not usually warrant tubes. My doctor and specialists only recommended them after multiple antibiotics had been tried unsuccessfully.

Best of luck to you and your son.