Insurance denial

[badfaith]

What is the name of your state? What is the name of your state? CA
I recently underwent surgeries for my back since July2002- Dec 2002. My policy states that it does not cover for any pre-existing conditions.
My insurance company paid for the treatment of initial surgery and other treatments in full.
I had another major surgery for the same problem in Dec 2002.
Now, my insurance company says that my problem is a pre-existing condition and that I am not eligible for the payments.They are demanding a refund of the already paid amounts for the treatment and denying the payments for the recent surgery.
The team of doctors and the hospital say that it is not a pre-existing condition and that the insurance co needs to pay for the treatment.The doctor also sent an appeal.Still they denied the payment.
I also faxed an appeal earlier stating that it was not a pre-existing condition and they could consult the doctor for any further clarifications.
I strongly feel this is a typical case of a "Bad Faith " insurance co.
Is it advisable that I hire a lawyer asap as the bills have started pouring in and the insurance company has not responded to my appeal and I am having sleepless nights pondering over this

Thanks

 

[badfaith]

Quick help on the topic is greatly appreciated

Thanks

 

[CIAA]

badfaith,

It is impossible to provide an opinion based on the information provided.

When was the coverage issued? What type of coverage? Is it an individual or group policy? Employer based? How does the preexisting clause actually read? What was the condition causing your claim? What is the history of this condition? Why does the insurance company believe it is preexisting? Why do you believe it is not? What did your doctor actually say?

 

[badfaith]

Hi,
The coverage was issued in Jan 2002.It is a group policy and employer based.
The pre-existing clause reads as follows:
Any injury,physical defect,medical condition or recurring illness which existed during the 5 years prior to the date of entry of You to the insurance.

I have been a normal and active person and there has been no history of problems of any kind.All of a sudden since May onwards , I started getting this back pain and wasnt able to walk after 10 days.It became so serious that I started losing sensation in my feet and the pain was unbearable.This was the condition that I was treated for.

There is no history of this condition until May 2002.

The insurance company says that their medical team finds that it is condition existed before and dont divulge details.

I do not believe it is a pre-existing condition because my doctor told me before I got the treatment and I had no history of any problem.Moreover as per the doctor, the condition I am suffering is basically due to a traumatic injury which could have been caused by lifting a heavy object or slipping,etc.

My problem started from May 2002 and the doctors state that there is no evidence that it existed before May 2002 and the pre-existing condition does not apply.Infact, my surgeon has resent an appeal stating that it is not a pre-existing condition and the payment for the treatment should be paid accordingly.

One should also note that the insurance company paid before for the same condition to the providers.Since that treatment was not successful, I had to undergo another treatment.At this point, the insurance company is asking for a refund for the treatment that they have already paid and stating that it is a pre-existing condition.All after 7 months into the treatment!!!

 

[HomeGuru]

Hire an attorney to sue the insurance company to force payment under the policy.

 

[badfaith]

Home Guru,
Thanks for the reply.I wanted to make sure if I had a solid case to go to an attorney.Your reply is encouraging.
I was just wondering if it would become an expensive affair if I need to hire an attorney? Is there any kind of Consumer Grievence forum where the services could be affordable?

Thanks much

 

[CIAA]

badfaith,

You should get some good professional advice, but you should also act with an excess of deliberation. It appears that your health plan will be an ERISA plan and you should find someone who specializes in this area.

When dealing with ERISA claim denials it is very important that you perfect your appeal as much as possible and the filing of suit to soon may result in crucial evidence not being admitted, as the filing of suit can effectively close the administrative appeals process and therefore the record. Unfortuntely, ERISA does not allow for attorneys fees for work done prior to filing suit and yet how you handle your appeal prior to suit is extremely important. Also, you need to make sure that you either exhaust the appeals process or that you are not required to (see ERISA amendments Nov. 2000); otherwise your suit may be dismissed. Finally, even if you win the lawsuit the awarding of attorneys fees is discretionary and ERISA plans are generally exempt from state bad faith claims.

In your particular case it may be that the insurance company may has several very qualified physician experts telling them that because of the advanced nature of the condition it had to have come into existence prior to January 2002. If your plan gives the administrator full discretion (as most do) than you usually must prove that the insurance company's decision was "arbitrary and capricious"; as one court put it, you must prove their decision was "totally unreasonable".

The handling of ERISA denials is full of pitfalls and is extremely dangerous for claimants. The most important thing at this point is: (1) GET QUALIFIED LEGAL HELP (2) DON'T LET YOUR RIGHT TO APPEAL EXPIRE WHILE LOOKING FOR HELP and (3) learn as much about ERISA as you can (use the Web, particularly the U.S. Department of Labor as they have regulatory and enforcement authority over ERISA plans)

Disclaimer: We are not attorneys and do not give legal advice or legal opinions. Any opinions or comments in our response should not be regarded as a substitute for professional legal advice.

 

[badfaith]

Hi,
Thanks for the reply.
Here are 2 things that I would like to update on:
1. I got a letter from the insurance company yesterday to my Employer's PO box which states that they have received my appeal regarding the declination of the claims and they are in the process of reviewing my appeal.They also state that a letter will be sent regarding their decision.

2. I misquoted in my earlier post when I wrote "their medical team". The letter said "their medical director". So I assume they may not have an expert team.I underwent the treatment in a highly reputed hospital (non-profit org) and it was not just one doctor who looked at my case and all of them said it was not a pre-existing condition.

I am not sure if I have an ERISA plan.

Thanks

 

[CIAA]

badfaith,

If it is employer group coverage I believe the chances are 99.9% that it is going to be subject to the ERISA regulations.

The fact that it may be ERISA does not necessarily mean that they don't have to follow some rules and I would expect that their policy provisions would have to conform with state insurance department rules on policy language for policies issued to California residents. The "pre-existing" clause that you quoted did not sound like something that would be approvable for group disability coverage (eff. 1/01/2002, Cal. calls health coverage "disability coverage). I did some look-up and it looks as if California Insurance Code Section 10198.7 (a) may be applicable:

"10198.7. (a) No health benefit plan that covers three or more persons and that is issued, renewed, or written by any insurer, nonprofit hospital service plan, self-insured employee welfare benefit plan, fraternal benefits society, or any other entity shall exclude coverage for any individual on the basis of a preexisting condition provision for a period greater than six months following the individual's effective date of coverage, nor shall limit or exclude coverage for a specific insured person by type of illness, treatment, medical condition, or accident except for satisfaction of a preexisting clause pursuant to this article. Preexisting condition provisions contained in health benefit plans may relate only to conditions for which medical advice, diagnosis, care, or treatment, including use of prescription drugs, was recommended or received from a licensed health practitioner during the six months immediately preceding the effective date of coverage."

Hopefully your appeal will be upheld on what you have sent. ERISA regs. allow them 60 days to review your appeal. In the meantime it might be very helpful to write and file a complaint with the California Dept. of Insurance, explaining your problem and asking them if your policy definition of preexisting is proper.

All the best.

 

[badfaith]

Hi
The information posted has been very helpful and encouraging. I hope I can resolve this asap as this is getting onto my nerves.
Any other information that I need to be careful or take some proactive action is greatly appreciated.

Thanks

 

[zappy]

The insurance company says that their medical team finds that it is condition existed before and dont divulge details.
============

Well this is the key point, let them prove you had this condition before you obtained the insurance from them.

If you are telling the truth and they cant, well they will have no choice but to pay, and for any future surguries as well...

SO man DONT LOSE YOUR JOB!

 

[lkc15507]

60 days to appeal is according to older regs. New regs differ. The time periods are shortened for ERISA plans--effective no later that Jan 2003. (I think this will often apply to many non-ERISA plans as well.) Oops, ins does have 60 days to review the appeal.

Also, food for thought: 5 years seems way outside the scope of preexisting condition clauses regardless of plan type, and, I have a problem with state laws applying to an ERISA plan unless the conditions of that plan are more stringent than the federal regs.

Zappy, shut up. You haven't a clue.

 

[badfaith]

Hi,
I got a call from my insurance company stating that they will review my appeal in a couple of days.So I can assume that I will not have any problem with the number of days as they have responded to my appeal.
Hopefully things work out well and without much hassle.

Thanks