denial of medical benefits by health insurance company

[demps bannerman]

My wife has been hospitalized twice for hernias and subsequent surgeries. She had the first surgery the 28th of May which was approximately 3weeks after the new policy (Provident) went into affect. The insurance company denied payment stating that this was a "preexisting" illness. A response was made to this indicating that this was not true-that this was never a preexisting illness/condition. I received another letter - this time stating that according to the contract, there was a 6 month waiting period for coverage of hernias, appendicitis and other related-type procedures. It was noted in the same paragraph of this exclusion that "this waiting period is rescinded if this was an emergency condition which required hospitalization and surgery withing 72 hours of hospitalization". Surgery was performed within 4 hours after entry into the emergency room. This has been brought to their attention yet they still evade my questions and state they continue to stick to the fact that there is a 6 month waiting period although it is plainly written in black and white about the exclusion.

In October, she had recurring surgery for the hernia. Again the insurance company has refused to pay. I sent several letters and I had received various responses. The first indicated that it did not pay for diaphramatic hernias until after a 12 month wait!!! (this was no diaphramatic hernia and there was no mention whatsover of the term diaphramatic hernia OR a 12 month waiting period). The second letter of denial was once again due to the 6 month limitation. I contend that this was a recurrence of the original May surgery which according to their own contract should have paid. As a result, I am out approximately $24,000 which I can not afford, and my credit has suffered since the hospital has turned the account over to a credit bureau. (I waited for the insurance to pay before making payments to the hospital for the second surgery). It took this insurance company until February 5, 2001 to deny payment on the October Surgery. What rights do I have and what can you suggest? We are residents of Mississippi. Thanks!

Demps Bannerman

 

[lawrat]

I am a law school graduate. What I offer is mere information, not to be construed as forming an attorney client relationship.


Of all the lawsuits naming insurance companies (especially health insurance companies) as defendants that I would see on a daily basis, the most prominent cause of action has been failure to provide services, bad faith breach by the insurance company.


To follow them, and they are quite successful, hire an attorney to sue this insurance company. Also, contact the state Insurance Commissioner on it, as well. They will launch their own investigation.

http://www.attorneypages.com or call your state bar association.