Ins co. trying to deny claim

[herbgreen]

What is the name of your state?
Illinois

Greetings,
I will try to keep this brief as possible and explain it thoroughly. In April I underwent an emergency gall bladder removal procedure. This is my first year with this carrier and it is my understanding that doing a pre existing investigation if there is a major claim in the first year of a policy is pretty standard. Is this correct? Regardless, I didn't mind because I had nothing to fear, or so I thought.

The process has taken months and I have been fending off folks wanting their money. I have been stuck paying out of network fees for the anesthesiologist and some of the radiology. Since it was an emergency admission I really had no chance to choose or review who they used but I did not press the issue. The main sum in question is the hospital bill which is over 40k.

I received a letter over the weekend from the insurance company stating that they had found a discrepancy on my application and the have asked me to address it in writing. It seems that I neglected to check yes to one of the questions which asked if I have ever received treatment for a gastro issue and I answered no when, in fact, I had. In September of 2003 I went to the doctor with chest pain. She diagnosed it as reflux due to stress ( I was pretty hammered by responsibility at my previous job, now I am unemployed) and prescribed a one month prescription of Protonix. I took the meds for less than a week and the condition went away. Months later as I was signing up for the new policy I completely forgot about that instance. It was genuinely an honest mistake. Now I believe they are going to use that to deny my claim.

What are my rights here? Do I have any recourse?

They have asked that I respond to their mailing in writing within 10 days which means that I only have about 7 left. I have been advised not to put anything in writing to them until I consult an attorney. Is that necessary at this stage? Please advise. I have two small children and no income right now. If they hit me with this it will be quite difficult to recover.

Regards
Herb

 

[cbg]

Very, very important question. It makes a difference to at least part of the answer.

Is this individual insurance which covers only you (and your family) and which you alone pay for, or is this employer-sponsored group insurance which has your co-workers under the same coverage umbrella and which is at least partially paid by your employer?

 

[herbgreen]

Hi cbg,

The plan I have now is individual insurance covering me and my family. I bought it after being laid off from my last job and is the plan in effect when I had my surgery. It is underwritten by Fidelity but administered through Insurers Administrative Corporation. At the time of the date in question in 2003, I was under my previous employers insurance.

Regards,
Herb

 

[cbg]

Chances are at least reasonable that they can legally deny the claim.

I asked if this were employer sponsored group insurance because there are certain rules that apply with such plans that, unfortunately for you, do not apply here.

I am willing to take you at your word that it was an honest mistake; however, it is likely to be a costly one. That information would have be included in making the decision as to whether or not to issue the policy at all and, if issued, what the premium would be. There are just a couple of states and I do NOT know if Illinois is one of them but I don't think it is, which are called guaranteed-issue states; that means they cannot deny the policy. However, even in a guaranteed issue states, information such that which you omitted, can be used to determine the cost of the policy and whether or not any pre-existing conditions apply.

The omission of this fact MAY HAVE (I do not say WILL HAVE) resulting in your being issued a policy in error; or one that was at an incorrect premium; or one which should have included a pre-ex clause. IF that proves to be the case, barring a state law to the contrary, the company may well be able to consider this a pre-ex condition and deny coverage. A lot will depend on the wording of the policy.

To be honest with you, while I'll accept your word at face value that you'd forgotten about the incident, if you had the surgery in April and the previous incident was in September, and if you had the September incident on your old insurance and the surgery on the new, that means that it had been, at maximum, less than seven months when you completed the application for new coverage. And that there was only seven months between the two incidents. I'm not sure, if I were an underwriter, that I would consider "I forgot" to be a creditable statement under those conditions.

By all means take a copy of your current policy to an attorney who is versed in insurance law, and let him review the applicable sections. But I'd say there is at least a reasonable chance that you are going to be out of luck.

Caveat: Obviously I have not read your policy and I do not know Illinois insurance law.

 

[herbgreen]

Thanks for the reply cbg.

Yes it was an honest mistake and I am kicking myself every day for it. Unfortunately honesty, goodwill and the law often travel separate paths, especially when money is concerned and, as you stated, mistakes like mine can be costly. I am referring this to an insurance attorney to see what s/he has to say. Thanks again.

Regards,
Herb