insurance denial question

[ChouDoufu]

this is an update from the below previously posted posting in a prior post.

current insurance is pretty worthless, especially now that the provider
switched from an australian to an american carrier. i went ahead and put
in a claim for january's avr.....not really expecting to have anything
covered, just who knows, maybe they might reimburse a small percentage.

going as expected, everything is denied. but the reasons seem to be
pulled out of their....elbows. have sent several emails questioning the
denial, each time the service rep chooses another exclusion at random.
but then each time i explain why that exclusion doesn't apply, they
have a different rep respond with another arbitrary exclusion. it's like
they don't bother to read anything i send...at least no more that the first
couple words, which allows them to select a boiler-plate denial message.

i understand it's their job to deny claims, and the more ignorant they
seem, the easier it is. i'm sure most people just give up after a while,
and that's what they're hoping for.

well, i finally got all my reports sent in, even the chinese ones. the insurer
wanted to have their own translation done, which makes sense.

several weeks later, i get two messages:

1) the translated documents have been reviewed and claim denied.

the documents were echo reports showing that i was stable. of course,
the explanation that the reports were in error meant nothing. i explained
that the chinese report showed an eva of 2.0, while the angiogram in
india showed the eva actually at 0.6

i requested a copy of the translation, but they refuse, claiming it is an
internal document. my question is was the translation correct, and did it
agree with my own translation? and my next question....what does it
matter, since the only report that is used in determination for surgery
was the angiogram?

2) coverage is only provided when more than 100 miles from home.

like, dude. i'm in southeast asia. that's about as far as you can get
from home in texas without entering an alternate universe.

so....calling lisa in katy. where do i go from here?

 

[Jkm7]

I'm getting high blood pressure just reading the dance they are putting you through.
I so hope that Lisa and/or someone else can assist.

Good luck.

 

[Lisa in Katy]

Well, I don't know what kind of benefits you have, and working with foreign hospitals isn't something I know anything about, but the second one sure sounds stupid to me, and as far as not giving you the translation, I just don't know. Makes me wonder if they actually did it. If you were in the US, I'd say to get your doctor and hospital to fight it, but since you aren't, and the providers are already paid, they have no incentive to get involved. So, it looks like you have 2 choices - 1) Continue to fight for something that you didn't think you were going to get in the first place, or 2) Say, "I told you so" and move on.

If you choose to fight it, I would recommend that you read your policy from cover to cover, write a final letter of appeal, quoting from your policy, and send it to someone closer to the top of the food chain (Chief Medical Director, CEO, etc.). Those have a way of making it to the people who can actually see past the script.

For everyone else reading, this is not the method that you should be using every time you have an issue with your company, or you'll get filed in the "cries wolf" category. Follow the correct channels, but if you are getting the runaround and things aren't making sense (not just that you don't agree with the decision), it is a last ditch option.

 

[Ross]

You might have to get on your bike, ride back to the states and kick some arse!

 

[westie]

insuance co

insuance co

.
are you dealing with a major, usa based insurance company?

 

[ChouDoufu]

it's a moderately major carrier for expats. coverage was much better with
the australian carrier. have been with them about three years, first two
with the ozzies, this past year with the sons of satan. will be switching to
a thai based policy for expats when re-upping in october.

guess i'll never see anything from these guys, after the policy ends that'll
be it. or i could stay with them twenty years until i need another valve, in
which case they'll say denied as they don't cover temporary prosthesi.

what really bothers me isn't the denial, it was sort of expected....it is a us-based
carrier after all.....it's how it's done. the first 10 denials were just canned pick one off
the menu automated responses that had little or nothing to do with my claim. c'mon,
denial for no cosmetic surgery, no experimental treatment, not 100+ miles away. it's
like they didn't even read my claim.

the thing with the translation is weird. why/how could they base a denial on a translated
echo (which they won't reveal their translation), when those echos were not the final
ones prior to surgery? they showed a relatively stable condition, and then the
angiogram, which gave a much better picture, showed a critical 0.6 eva deterioration.
they won't even tell my why the denial, just 'we've reviewed the translated documents'
and deny the claim.

so if i get hit by a truck and break both legs and have to spend a week in the hospital,
they'll deny my claim because i happened to have a report showing perfect health for a
pre-employment exam a week prior? they're apparently basing the denial on a report
stating the condition prior to the report stating surgery was needed.

fortunately, i didn't go through the us system, so didn't rack up $100k+
in bills, just a measly $12k. hey, i get to itemize for the first time ever!
see, avr has it's advantages.

back to insurance, i'd be happy to get anything from them. maybe they'll
give me 25% just to go away. of course, that'll screw up my tax planning.
i've been trying so hard to keep my tax at $0 since heading overseas in '05.

and you forgot option #3.....keep submitting claims, and keep collecting
the denial slips until i have enough to wallpaper the bathroom.

 

[Bina]

Don't the denial slips also make half decent bum wipes?

 

[ChouDoufu]

Don't the denial slips also make half decent bum wipes?

naughty girl! aren't you the one always complaining about toidy-talk
during breakfast? and here you start it.....

....and here i'll end it (if you know what's good for you )

bum wipes? nah, here in asia we're leading the world in environmentally
friendly technology.

we don't use anything as polluting and wasteful as paper for that purpose.

oh,no.....we use small furry rodents. hamsters, gerbils, leftover lab-rats.

their fur is absorbant, they self-clean, and they're reusable. until they get
really pissed off. well....maybe not exactly, um, pissed.

maybe you canuckians could try it, save your forests for important things,
like plywood. i'm aware youse guyse are a bit wider than the average
asian, so maybe you could use rabbits. rabbit. but no hares, especially
wild ones! you know what that could lead to...

bwahahahahahaha!!!!!!!!

 

[Bina]

We can toidy talk.....it's almost 10 pm over here.
Hubby says that small furry rodents are best kept away from....you know where.

 

[westie]

approval

approval

.
did you try to get or consider the possibility of "prior approval" from the health insurance company in question?

anyway, they really should be juming up and down in joy because you sure saved them a bundle by going to india.

 

[ALCapshaw2]

Chou -

You've got to get past the Id**t's and/or people who are ONLY authorized to Deny your Claim and get to someone (Manager / Supervisor) who actually has the authority to Approve your Claim.

As you have seen, you are only wasting your time with the "Naysayers".

 

[ChouDoufu]

i'm leaving monday morning, won't be able to do much for a month or so. will be
trying to get a hold of the secret evidence, their internal translation of chinese
echo reports that shoudln't affect the claim, but they're fighting that. kinda hard
to fight the denial if i don't have the information they're using.

kinda like trying to defend yourself at guantanamo with no access to the evidence.

 

[Tbone]

I would say that it is time to get some representation here in the states for yourself. My advise is to ask your friends who the most devious lawyer is in Texas & hire him. Have him start with a letter & go from there. You will have to pay for the letter but make the agreement that he gets the rest paid if & when you win.

Also, if you have to travel home for court than charge per hour for your time on top of hotel, plane tickets, and car rental with all gas used. Oh I almost forgot the meals prices are way cheaper in china.

Best of luck to you.