health insurance claim denied

[shan tien]

What is the name of your state? Colorado

My insurance company is denying my claim because they say it was a condition I had been seen for in the last year. They got records from my doctor that I had previously been in for a UTI. So they are denying a claim for a visit I had 4 months later for lower abdominal pains. They also said that my doctor had diagnosed me with something during that visit but they won't say what. However, he told me that he found nothing. Even if he had found something, I don't see how a visit for a UTI is a pre-existing condition relating to abdominal pains, especially when he didn't find that I even had a UTI during the second visit. I asked them if they would pay it if the doctor said that they aren't related and they said no. Are they allowed to do this? Can they deny a claim based on whatever they deem to be a pre-existing condition despite what the doctor says?

I also asked if I had the flu, and then went to the doctor for the flu again 11 months later if they would refuse to pay for the second visit. They said yes. I don't understand how getting the flu twice in one year is considered pre-existing unless it happens within the same month or so. Is that really how the insurance laws work? If you get the flu in January one year and then again in November of the same year, they call it a pre-existing condition?

 

[CIAA]

Can they deny a claim based on whatever they deem to be a pre-existing condition despite what the doctor says? I don't understand how getting the flu twice in one year is considered pre-existing unless it happens within the same month or so. Is that really how the insurance laws work? If you get the flu in January one year and then again in November of the same year, they call it a pre-existing condition?

Answer: NO....and if you ask them to put this in writing, they won't do it!

First of all, if this is employer based coverage you should have, by law, been advised of your right to appeal and you need to get good letters from your doctor refuting their denial. If it is private coverage, do the same thing and file a complaint with your state department of insurance.....if applicable.....let's discuss that.

Obviously, one infection , when resolved or cured, is not the same as another infection. From an insurance company perspective, a condition may be regarded as pre-existing if it has occured with such frequency and severity to be actually regarded, from a medical standpoint, as being a chronic reocurring condition. Usually the doctor's diagnosis will indicate the "chronic" nature of the condition, either by calling it "chronic" or by using a diagnostic name which means chronic. However, this doesn't really seem to fit your situation, so we need to further discuss what a "pre-existing" condition is:

Typically, a condition comes into existence when it "manifests symptoms which would cause an ordinarily prudent person to seek medical advice, consultation or treatment" (note: a diagnosis or even a correct diagnosis is not necessarily required; that is why they call it "medical practice").

So, in your case you saw the doctior 4 months ago for "abdominal pains" and diagnosed as having a UTI, which in retrospect may or may not have been correct. Now you return with the same symptoms and the doctor isn't sure what the problem is. Can the insurance company say that this is the same condition? Maybe, it depends on what has been going on for the past 4 months, what your doctor's best medical opinion is and what the doctor's records say. For example: " Originally diagnosed as UTI, prescribed____, got some relief but has continued to experience periodic pain and now returns with increased pain..." This type of medical record entry is indicative of a condition that came into existence 4 months ago, is causing chronic recurring abdominal pain and we're not sure what it is yet.......

Talk to your doctor and have him advise you and the insurance company if applicable.

Hope this helps.

Chet