Claim denial

[thefriend]

What is the name of your state? What is the name of your state? What is the name of your state? Minnesota.

My health insurance type is: Group Insurance of fully-insured type.

I have been admitted to hospital on 27th feb 2002 and was diagnosed for my sickness on 14th Mar 2002 and started treatement since 14th Mar 2002.
Because of prolong stay in hospital my medical expense went higher. My health insurance policy says that they cover everything till diagnosis is established.
Initially my insurance declined all the claim saying they are not the major medical plan. After multiple follow up they paid all the expenses till 1st mar 2002, saying my diagnosis was established on 1st Mar 2002, But it is wrong as i know and my doctor know and doctor letter i have says my diagnosis was established on 14th Mar 2002. The amount for expense between 1st Mar and 14th Mar is about 60,000 US dollars and the insurance is denying to pay this, saying diagnosis was done on 1st Mar 2002.
I have done multiple follow ups with insurance and my HRD but health insurance is not ready to change their stand on this. They indirectly offer me for 12,000 USD and asked me to negetotiate with the hospital but 12000 is just 20% of the total bill.

Pls. advice.
Your friend

 

[Beth3]

I don't understand the coverage in your group policy. Your medical bills are covered UNTIL a diagnosis is established????

So under your plan, if I went into the emergency room with life-threatening symptoms and they diagnosed encephalitis and admitted me, the ER visit would be covered but not the actual hospitalization???? I can't help but think you've explained the basis for the denial of your bills incorrectly or at least incompletely.

Please clarify if you can.

 

[thefriend]

I appreciate your reply.

I was admitted in the hospital with serious sickness and hospital diagnosis took 16 days to established that i have a tuberculosis. Now my policy says treatment of TB is not covered after diagnosis is done.
My insurance believe that diagnosis was established on 4th day not 16th day. On 4th day i was diagnosed with mantox positive and insurance is considering that as a daignosis for tuberculosis, but my educated doctor who was treating/diagnosing me in the hospital believe that diagnosis was done on 16th day and medication started after that .

This is the whole point, insurance has only paid for 4 days whether they should have paid for 16 days till diagnosis is established.

Pls. let me know if it does make sense.

Thanks
Pankaj

 

[HomeGuru]

Something does not make sense with respect to the actual facts.

 

[Beth3]

Pankaj - it sure doesn't make a whole lot of sense to me why your group policy would specifically exclude treatment for TB. Is your employer/insurance carrier looking to make this a common illness again??? (HG, I agree that the facts still don't make much sense.)

In any event, I take it you don't argue that treatment is excluded from coverage but rather you're debating the date the actual diagnosis was made. Your options are to file an appeal with the insurance carrier (info on that will be in your plan document/insurance booklet) and if they deny the claim, then to file an appeal with your State's Insurance Commission. If you're still not satisified, then you can sue.