Health Ins. claim review delay

[blumoon4_2]

I am a Missouri resident with group health insurance w/Aetna. Policy started 12/01/00. Doctor has been trying to get Aetna to authorize a much needed treatment for oseoarthritis in my right knee. This is the only relief from pain I am able to get as I am too young for knee replacement surgery. This authorization normally takes ONE week to get. This is the first time this Doctor has had such a problem. Now I need, as of 2/27/01, the same treatment in the left knee. This is not experimental, and the doctor's office has been in touch with Aetna and sent them documentation requested. I have called numerous times begging with them to expedite their review process as the quality of my life is being affected by this delay. It is not important nor is my pain the issue, it just takes time to get the information needed to make this review and I should refrain from getting upset with them. I am un able to work obviously, and at this point and time, do NOT know if I will be able to. Can they do this to people without us being able to fight back. MO insurance law says they have two working days to review and advize.

 

[ALawyer]

Call your employer's benefits office (you said it was group insurance) and ask it to interecede on your behalf with Aetna.

 

[blumoon4_2]

My work called, the adjuster who sold plan called, the doctor's nurse called and even the Doctor himself. The adjuster found information on treatment and it's coverage on the same day of contacting him. He does not understand either and agrees that they are in the wrong, but is at a loss as what can really be done other than complain.

 

[ALawyer]

The insurance department may have no role as group plans are often exempt from state regulation under ERISA but ask them and the MO state government unit who regulates health plans if different (in some states health plans are regulated other than by the insurance department) and also writ to your US Congressperson to complain and ask assistance because it is Congress which exempted the plans from state insurance regulation and now the carriers have no one to fear but they do not want to anger, or have Congress reconsider.