Claim Denial during COBRA coverage is a Surprise

[PainDelux]

What is the name of your state?What is the name of your state?What is the name of your state? IL

I have had a hell of a time with a claim to my insurance company after leaving my company for another job. I left 11-04 and had coverage through COBRA until 1-31-05. During the time that I changed jobs my company changed from Blue Cross Blue Shield HMO to United Healthcare after the new year. On 12-26-04 I had an issue that I needed to go to the ER for. I followed up with my PCP to get a referral for a CT scan that I had completed on 1-5-05.

I just received a denial from United Healthcare for the $3860 for this procedure because "According to your plan, benefits are only available when a network physician or health care provider is used." This letter has made very angry at how an ongoing medical issue that should be covered through COBRA or so I thought now is getting denied because I did not already have a new PCP for the new plan right after the New Year. Is there anything I can do to write an appeal for this based on the fact that it was an ongoing follow up from my previous plan physician or any other reason? It is completely absurd to me because both providers will try to not pay because it was my employer deciding to change plans in the middle of COBRA coverage...so it IS really as if I DO NOT have continuing coverage when COBRA is to give provided continuing coverage. Someone who knows pleeease help. Thank you.

 

[purple2]

Yes, you can file an appeal.

If you used an out of network provider and your policy only pays for in network providers, you are not going to win the appeal.

 

[PainDelux]

Appeal

But in my situation what can I reasonably do for the reason of the appeal? I can show that it was a continuing medical issue from 12-04. But of course the plans will have different providers, so what else can I have done? The plans should be able to make exceptions for things like this right? I just don't think it would have been reasonable for me to find a new PCP right then after the new year to continue what was started with the old doctor and old plan.

 

[cbg]

This has absolutely nothing to do with COBRA. The benefits on COBRA are exactly the same as they are when you are employed. Likewise, the restrictions are exactly the same on COBRA as they are when you are employed. It is entirely possible that United Health Care does not even know you are on COBRA. That's not information that would necessarily have been given them when the company transferred coverage; nor does it matter one whit to the payment - or denial - of any claims. COBRA is absolutely irrelevant in that regard.

If the plan requires that you use a network physician to be covered, the plan requires that you use a network physician to be covered. The rules don't change because you are on COBRA, and the rules don't change because you "haven't had a chance" to find a new PCP. Everyone else on the plan would have to follow the rules of the plan to get their bills covered - why should you be exempt just because you're on COBRA? That isn't how it works.

From what you have posted, you really don't have any grounds for appeal. You are free to try if you want to, but I wouldn't be holding my breath that you will prevail.