Claim denied - pre-existing condition

[StevenH]

My wife had exploratory surgery performed by her OB based on physical symptoms she exibited. Her insurance company verbally approved the procedure beforehand and then denied it based on a pre-existing condition that was treated during the procedure. New conditions were found and also treated. The reason for the procedure was not due to the pre-existing condition. Any advice on how to fight this?

Thanks in advance,

StevenH

 

[ellencee]

appeal the decision

Send a letter, via certified mail, stating that you are appealing the denial of benefits. Your insurance policy should have a written appeal procedure and you need to follow that procedure. There is usually a 30-, 60-, or 90-days time limit in which to file an appeal.

Read the hospital's billing statement and make sure the primary diagnosis (& ICD-9 code) is listed first and the secondary diagnosis (& ICD-9 code) is listed secondary. It is possible the denial of benefits was based on incorrect priority of ICD-9 codes.

The pre-authorization for surgery should have been documented by either the surgeon's office or the hospital. You should be able to use the documentation to show that the surgery was performed as authorized and for the reasons stated when the pre-authorization was obtained.

EC

 

[Ringer]

A preauthorization is not a guarantee of benefits. Did you have prior medical coverage before you were covered under this plan? The HIPAA/portability laws would elminate the pre-existing exclusion as long as you had prior coverage for 12 or 18 months, (depending if you were a timely enrollee or late enrollee, if a group plan), and did not have a gap in coverage of more than 63 days. I would speak to your insurance administrator or insurance agent. If you had no other coverage the claim is pre-x. You can appeal but the pre-existing language is always clearly explained in policies.

 

[terry32561]

the key is prex

While they were operating on a new problem decided to treat the the prex, you probably won't win.