Advice for Daughter, Med insurance problem $34K

[oilboy123]

My Daughter had a knee operation a couple of months ago. She had asked the insurance company about getting the operation done and was told she needed no approval. Now they are coming at her wanting $34K and saying that the knee problem was not an injury event, but a long term condition from playing La cross.

She is going to try to get more info about the situation.

Does anybody have any tips, or advice that I could pass her way?

Thanks in advance Pat

 

[crinkles]

sorry for the situation you guys are in. the greed of these companies are unbelievable. good luck getting it sorted. I suggest a good lawyer.

 

[PandaBear]

If she was insured the whole time even include her time playing La Cross, I don't think they can claim pre-exist condition on that.

Note to self: this is why everything verbal should be followed up with a written notice. I learned this from a lawyer that keep sending me certified letter with "We have agreed upon this term in our phone conversation, if this is not the case please send us a written notice" kind of letter.

If I were you I'd stick to my gun and threaten to get an attorney if they are not paying, as well as complaining to the insurance commissioner of your state.

 

[Shannow]

I'm really sorry to hear about your situation.

And even sorrier that some on here feel that such is right.

 

[rshaw125]

She just got the bill months after the op? Something does not sound right here. If She owed anything she would have been informed before she left the hospital.

 

[aaxb970]

I guess she should have got the approval on paper. Lawyer ??

 

[oilmaven]

I'm usually not willing to get into these discussions but am going to on this one. This "don't pay deny the claim" mentality is becoming the norm with health insurers. It would seem that in many cases, even if the procedure is clearly covered it's simply denied...and the patient has little or no recourse. Rest assured that the health care provider will want their money...or else (like collections, a bad credit rap or worse). This goes on ALL THE TIME and we sort of just accept it (complaining all the time about it). Meanwhile, the mega-companies that now control health insurance are reaping HUGE PROFITS...in the 10's of billions per year. Health care has become a big-money business...like everything else...and the little guy is paying for it...with his health, his credit and sometimes his life. As far as the US having the best health care in the world?...the fact that many (including the newly unemployed) have NO health insurance makes that statement a joke. The cost of the care is becoming so high that many can't take advantage of it anyway. Those of us that DO have insurance will still be bankrupted by the costs left over (that we are responsible for) after any major or longer-term illness. I'm not convinced that the recently passed health care bill will solve any of these problems. Polls indicate that the majority of Americans oppose the bill...though most haven't bothered to find out what it actually is. The mega-companies and their political hacks in Congress have done a good job in demonizing ANYTHING that doesn't continue the present system.

Meanwhile, I read an article that stated that some of the insurance companies are proposing a "65-35" plan to replace the current "80-20" plans (they pay 80% of the costs up to a pre-determined amount). In other words, YOUR part of the bill would rise to 35%...almost double what it is now. Sound impossible? Don't bet on it.

At the rate we're going, we will eventually return to the system that existed before "insurance for the masses" came along (mostly as a result of employer-provided health plans). Only people with a lot of money will receive anything resembling comprehensive health care. The "masses" will simply do without or be forced to accept less and less care. I'd say THAT plan is working out rather well.

 

[saberz]

We wouldn't need insurance if there weren't inflated procedure prices and lawsuits. Insurance has risen with the rise of lawsuits.

 

[Al]

Originally Posted By: oilmaven
I'm usually not willing to get into these discussions but am going to on this one.


Thanks for the irrelevant rant.

Oilboy: What was the specific reason that coverage was denied.. Preexisting condition? First step is to challenge their ruling. Might be worth a lawyer.

Good luck.

 

[rshaw125]

Originally Posted By: aaxb970
I guess she should have got the approval on paper. Lawyer ??


As in my previous post. Something is NOT right here. The hospital confirms who is paying BEFORE they do the op. And any residual expense is gone over before you leave. So all the rants about health care are a bit premature.

You don't have an op and receive a bill months later.

 

[refaller]

The same thing happened to my wife. It was months later that the hospital came back saying the company (who said we didn't need approval) was now saying it was a pre-existing condition. We had the doctor send a letter saying that it indeed was not (same body part, different condition), but nothing changed. Hire a lawyer.

ref

 

[bluestream]

If she needed a knee operation what difference would it make if it was caused by playing Lacrosse? Fact is that she needed the operation. I would say they are just testing you on this to see if you'll roll over and go away. I would not pay a cent and get a Lawyer if you have to, Problem is the Lawyer will end up charging you 17K in fees to get you off the 34 K

 

[Vikas]

If you want real help, get hold of your congressperson's office.

 

[stockrex]

Create a web site or blog, call Ur local tv station. Keep sending them notices in reg mail. Post all on blog. Start letter writing campaign...

 

[JHZR2]

I agree with bluestream, what difference does it make? I cam maybe see it if the person is prone to heart attacks or something like this, that there is a "pre existing" condition. However, does anybody really want their knee operated on just for the fun of it? This needs to be thought out logically.

If someone was uninsured and hurt their knee, then signed up for insurance to cover it, this is like buying car insurance after you crash your car into something, and then claim the crash happened a few days later than it did... that is wrong.

But if someone has nursed their knee injury for some time, and age, time, other circumstances has caused it to get to the point where operations are necessary, I dont see it as logical that this is the same sort of preexisting condition... Nobody wants to go get surgery, IMO.

From what I have seen, these insurance companies bill/pay incorrectly, and they try to get away with whatever they can. I had the payment for a doctor's visit go to collections once, because the insurance billed/paid it wrong. Once I talked to them for the twentieth time and got them to straighten it out, it was paid no problem.

Why does the insurance company know about her lacross playing habits anyway?

All that said, and whether they have student loans or not, the amounts that these doctors charge for the knowledge they hold is scary. Most doctors do not truly understand the underlying chemical, mechanical and electrical basis for why things occur in the body. A surgery is a bit different, as they are in theory, repairing something better than it was, but most of these treatments just mask underlying issues of which they do not understand...

 

[Burt]

Sounds like the insurance company believes that living is a pre-existing condition.Let me get this straight: the policy says it covers "injury events" and not "long term conditions". How do they know she played Lacrosse and for how long? Did she have medical treatment for it that shows up on her records? How long has she been on insurance before she had the procedure done?

 

[The_Jeff]

Originally Posted By: rshaw125
Originally Posted By: aaxb970
I guess she should have got the approval on paper. Lawyer ??


As in my previous post. Something is NOT right here. The hospital confirms who is paying BEFORE they do the op. And any residual expense is gone over before you leave. So all the rants about health care are a bit premature.

You don't have an op and receive a bill months later.


I have. The bill comes much later. My insurance lets you go up to a year, and the hospital/doctor drag it out to nearly that long.

When you present your insurance card for a procedure, it's only in good faith that they'll cover it; you sign something saying you personally are on the hook-- believe me.

It would be pretty sweet if you could hobble into an ER and get an exact price rundown and guarantee that your insurance works. Some HMOs and preferred (not participating) providers work this way. Not my guys.

Would also be pretty sweet if (non profit!) hospitals had some staff attorney/social worker to help people sort their bills out. My hospital billing dept NEVER answers phones; makes you leave a voicemail with your account number and problem. I got an automated form letter once about a bill that was dragging out saying "we have not heard from you." I fired back a letter saying that was an outright lie, I called so-and so on date/time and she refused to answer.

Anyway, document everything. Is this an employer health insurance plan gotten during open enrollment? They usually cover pre existing conditions.

You may also have the Dr get pre-qualification after the fact from the insurance; they can do that.

 

[oilmaven]

Irrelevant rant?...and then you advise a lawyer? I will apologize for my lengthy "rant" but have been victimized by this same type of situation (albeit for a considerably smaller sum). The fact that we consider these "challenges" and "legal actions" normal when dealing with these situations speaks to the problem. A lot of damage can be done before any (IF any) result is reached...and time (and money)is on their side. This sort of thing doesn't just happen occasionally...it happens all the time. It all seems irrelevant and overly emotional...until it happens to you.

 

[onebigunion]

oilmaven -

You are exactly right, not sure how someone could claim your words are "irrelevant". The only thing I would disagree with in your words is that I think we are ALREADY at the point where comprehensive (or even barely adequate) health care is the province of the very wealthy.

Having "good" insurance is nowhere near sufficent protection against catastrophic medical costs. There are so many weasel words (and the new favorite - "codes") that insurance companies use to deny legitimate claims. You're right - it is now becoming almsot standard practice to deny ANY major bill and force the insured to litigate - guess which side has more resources to be able to handle that.

The bogus claim that the medical costs are so high because of the generic buzzword "lawsuits" is ludicrous. Insane profit margins for insurers and even more insane bonuses for their executives are a MUCH larger factor, by orders of magnitude.

And you're also absolutely right that these bills often come months or even longer after the procedure - makes it MUCH harder for the insured to make their case - documnents lost, providers no longer working at the same place, etc.

And if you think it's bad now, wiat a few years. Health care "reform" did virtually nothing.

 

[CivicFan]

Originally Posted By: rshaw125
Originally Posted By: aaxb970
I guess she should have got the approval on paper. Lawyer ??


As in my previous post. Something is NOT right here. The hospital confirms who is paying BEFORE they do the op. And any residual expense is gone over before you leave. So all the rants about health care are a bit premature.

You don't have an op and receive a bill months later.


In our state a bill is a courtesy, not a right. That means that even if a person doesn't receive a bill, s/he can be taken to court and will lose the case.