Insurance Company Refusing to Pay.

[Granz]

What is the name of your state (only U.S. law)? New Hampshire

Hello, I am 38 years old and last year I had a heart attack. I ended up having 3 stints put in my heart because of blockages that I had. I was 13 days away from being covered by my current health insurance company Cigna. They obviously refused everything from that claim that was 13 days before coverage. They did cover a stress test and a MRI that I had done 3 days after I had the insurance on July 3rd 2008.

Now in January of this year I had 3 other blockages and they are calling some parts of the total bill pre-existing. They paid the doctor to do the actual surgery but they refused to pay the hospital that I was in. They also refused to pay the Stress test that I had done that the doctor ordered before the actual surgery. It was the exact same stress test that I had done last July for a follow up and they paid that. I am appealing that decision too.

Can they do this? I have sent a letter of appeal because this is insane that they paid the doctor but won't pay for the surgery to be done in a hospital.

How the hospital wants to set up a payment plan. Well I can't afford what they want from me and they are saying they will send it to a collection agency. It is a non profit hospital but I am afraid they will try to muscle me and put a lien on my house or something...

I am in quite the jam... :/

[cbg]

Is this an individual policy or an employer-sponsored group policy?

Did you have previous coverage prior to the inception of this plan? If so, was there a gap between the end of the old plan and the beginning of the new plan? If yes, how long was the gap?

[ecmst12]

You may find the result of your appeal based on past payment will result in the past payment being taken BACK, if it was in error in the first place.

Have you read your policy's exclusion clause for pre existing conditions?

[Granz]

Originally Posted by cbg

Is this an individual policy or an employer-sponsored group policy?

Did you have previous coverage prior to the inception of this plan? If so, was there a gap between the end of the old plan and the beginning of the new plan? If yes, how long was the gap?

It is a group policy through my employer. I didn't have coverage when I had the heart attack. I was more then 2 years I was not covered prior to the heart attack.

[cbg]

In that case, the insurer has the right to deny claims that have been legitimately identified as pre-existing for up to 12 months after your enrollment.

[Granz]

The question is it a legit pre-existing claim? These where new blockages in my heart that I didn't have before. So now if I have anything happen to my heart they can scream pre-existing? I mean if I had another heart attack tomorrow they can say "no you did this before"? For how long can they do this?

I also don't see how they can pay the doctor but not the hospital. It doesn't make any sense. The woman that I called at Cigna said paying the doctor was not a mistake. I even asked her this.

This bill is 80 thousand dollars. I can't pay this. I have offered to pay the hospital 200 dollars a month (Of which I really can't afford.) The hospital is saying they are going to send it to a collection agency. Besides marking my credit what can a collection agency do to me?

[cbg]

If you had treatment 13 days before the coverage began, and you had not had insurance coverage for two years, then yes, it is a legitmate pre-existing claim. They don't get much more legitimate than that, in fact.

On an employer sponsored group plan, the longest they can call a condition pre-existing is 12 months. That is Federal law. Therefore, if your coverage began on July 3 2008, then the condition ceases to be considered pre-existing on July 3, 2009. I believe that state law in NH puts a nine month limit on it which would mean that it ceases to be pre-ex on April 3, but I am not certain of this; it's been too long since I had employees in NH.

I don't know why they paid the doctor and not the hospital but given the dates that you have described, I can't see any way that this is not legitimately pre-existing.

[ecmst12]

The fact that these are "new" blockages is not relevent. You had a diagnosis of coronary artery disease prior to your effective date. You still have that diagnosis and that diagnosis is the reason for the more recent surgery. CAD is an ongoing condition which causes blockages, the blockages themselves are not the diagnosis but the symptoms. Nice try though.

[Granz]

So what are my options? This is 80 thousand dollars. I am sure I can get that lowered considerably but still. The hospital wants me to fill out a financial aid form. But I fear that. I have looked it over before but I won't qualify because they want you to be only making 38k for two people. My wife and I make more then that but we are not rich we make around 60k and have 1500 dollar house payment, car payments and such. I am afraid to fill out the form then they will have me and know everything about me. Christ I drive a 9 year old BMW with 110k on but it will look bad because it says BMW on it. They say they won't do that and they say they will be able to lower the bill even though I don't qualify for the 38k for 2 people.

This is a non profit hospital. They are saying they will send it to collection. Is collection that bad? I tried to set up a deal for 100 a month and they sent me paperwork that I signed to agree to it and the administrative office denied it and sent back my check saying they want more then that. Can I just pay 100 dollars a month forever to the collection agency? Should I allow it to go to collection? Without them being able to do anything to me. This is not like I bought a corvette and am refusing to pay for it. I had a damn heart attack and had no choice but to go to the hospital. I honestly put up with shortness of breath for a month and just couldn't take it anymore when my arm went numb and had chest and jaw pain. I tried to make the 13 days but my family insisted and they where right. I am afraid they are going to put a lien on my house and I will be ruined and homeless...

As you can see I am stressing... I just got my first house and don't want to lose it.

[ecmst12]

You need to work out a REASONABLE payment agreement. $100/month on a bill that high is not reasonable. And they don't have to accept payments at all, they can sue and get a judgement and put a lein on your house and garnish your wages and all that other fun stuff. So you definitely want to work with them to avoid getting to that point.

If you hadn't gotten your first problem taken care of when you did, you'd probably be dead. Being in debt is no fun, but death is definitely worse.

[Granz]

I can't afford more then 200 a month. I told them this. They will have to put a lien on the house I guess. They are going to make no money off that. The housing market is busted around here. You can't get blood out of a stone. The economy is not good I already took a 15000 a year cut in pay already. It will go to a collection agency in a month or so... They knocked the first bill down for the actual heart attack from 69k to 17k. This new one from January is another 59k. Hopefully they will do something with that.

[ecmst12]

The economy will not be bad forever. A judgement is good for 10-20 years or more and a lein lasts as long as you own the house. All you can do is the best you can for now, and when circumstances improve, do more.