Health Insurance question

[gar3555]

My 14 month daughter recently had a tear duct irrigation (@ 11mo), and our insurance provider denied the claim for all the surgeries, claiming a pre-existing condition. I didn't think a baby could have a pre-existing condition on something like this. Coverage started in Feb as my quit her job to take care of my daughter, and had to get her insurance. I don't know what to do, I know you can appeal, it just doesn't seem right to me, but what do I know. Do I have any legal options, or options at all? Sorry for the quick unscripted message, but I am pissed right now.

Pic of Wife and Daughter

 

[gar3555]

OP edited, treatment was actually tear duct irrigation

 

[Corporate Thug]

I'm sure there is an appeal process right?

 

[gar3555]

Originally posted by: Corporate Thug
I'm sure there is an appeal process right?

yes there is, and that is where I will be starting. I'm just pissed, and needed to vent.


Wondering if anyone had any luck with appeals, or is this just delaying the inevitable?

 

[spidey07]

Important question, was there ever a point in time when your daughter had a lapse in insurance coverage? I'm confused. Did you move your wife/daughter to your insurance?

 

[lykaon78]

Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

 

[gar3555]

Originally posted by: spidey07
Important question, was there ever a point in time when your daughter had a lapse in insurance coverage? I'm confused. Did you move your wife/daughter to your insurance?

She had quit her job to be a stay at home mom, and her work insurance was expiring, so we switched.

Originally posted by: lykaon78
Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

1. Yes, with a switch of plans when my wife quit her job.
2. Not that anyone knew about.

 

[tallest1]

Originally posted by: gar3555

Originally posted by: spidey07
Important question, was there ever a point in time when your daughter had a lapse in insurance coverage? I'm confused. Did you move your wife/daughter to your insurance?

She had quit her job to be a stay at home mom, and her work insurance was expiring, so we switched.

Originally posted by: lykaon78
Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

1. Yes, with a switch of plans when my wife quit her job.
2. Not that anyone knew about.

If your appeal gets denied. I would sooo sue over that. All you gotta do is find one news station to listen to your story and the public will laugh at how stupid it is for one to claim that a baby has a pre-existing condition.

 

[2Xtreme21]

God bless America. Don't you feel so free?

 

[KMFJD]

Originally posted by: 2Xtreme21
God bless America. Don't you feel so free?

You reap what you sow

 

[satyajitmenon]

Originally posted by: tallest1

Originally posted by: gar3555

Originally posted by: spidey07
Important question, was there ever a point in time when your daughter had a lapse in insurance coverage? I'm confused. Did you move your wife/daughter to your insurance?

She had quit her job to be a stay at home mom, and her work insurance was expiring, so we switched.

Originally posted by: lykaon78
Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

1. Yes, with a switch of plans when my wife quit her job.
2. Not that anyone knew about.

If your appeal gets denied. I would sooo sue over that. All you gotta do is find one news station to listen to your story and the public will laugh at how stupid it is for one to claim that a baby has a pre-existing condition.

This. Besides that fact that it's laughable that they're claiming the baby has a pre-existing condition, if the child was on insurance from the day she was born and there was no break in coverage, I don't think they have grounds to deny.

 

[Bignate603]

Originally posted by: tallest1

Originally posted by: gar3555

Originally posted by: spidey07
Important question, was there ever a point in time when your daughter had a lapse in insurance coverage? I'm confused. Did you move your wife/daughter to your insurance?

She had quit her job to be a stay at home mom, and her work insurance was expiring, so we switched.

Originally posted by: lykaon78
Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

1. Yes, with a switch of plans when my wife quit her job.
2. Not that anyone knew about.

If your appeal gets denied. I would sooo sue over that. All you gotta do is find one news station to listen to your story and the public will laugh at how stupid it is for one to claim that a baby has a pre-existing condition.

I would definitely contact your local news if the insurance doesn't help you, many have a segment where they get publicity for things where people are getting cheated. Once their name gets plastered up on the TV many companies are much more willing to actually do something.

 

[Proprioceptive]

My wife and I were denied claims for her pregnancy due to "pre-existing conditions" when we had Aetna through our university. She became pregnant 3 weeks after our coverage started... so I guess aliens impregnated my wife before we got married or something, and we even had documentation from the doctor stating that the conception date was 3 weeks after coverage started. It took us a year and a half to fight Aetna on that one. Eventually I think they realized we weren't going to give up. We even had to fight the collections agency and eventually had the negative marks taken off of our credit reports. We would have been out $6,000 dollars if we hadn't been so persistent. I HATE Aetna with the passion of a billion burning suns.

 

[sixone]

Originally posted by: gar3555

Originally posted by: lykaon78
Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

1. Yes, with a switch of plans when my wife quit her job.
2. Not that anyone knew about.

Call your current insurance provider, and ask if they have documentation that she's had continuous coverage. If they don't, get it from the previous insurer, and send it to the new one. They'll reprocess the claim, which should be paid at that point.

 

[SirStev0]

She is a child so IMMEDIATELY sign up for a CHIP program. It changes state by state, so it might not be an option for you (some require poverty and so forth) but hopefully you'll be in a state that makes sure she s covered.

This is a great example of the problems in this country. No one can deny that there is problems that need addressing when cute kids are left out to dry by the insurance companies.

 

[KMFJD]

This is why the us healthcare system is one giant fail...having to argue with insurance over the health of your child? GoGo Insurance companies!

 

[ebaycj]

Originally posted by: sixone

Originally posted by: gar3555

Originally posted by: lykaon78
Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

1. Yes, with a switch of plans when my wife quit her job.
2. Not that anyone knew about.

Call your current insurance provider, and ask if they have documentation that she's had continuous coverage. If they don't, get it from the previous insurer, and send it to the new one. They'll reprocess the claim, which should be paid at that point.

This.

Pre-existing is only a problem if you went without insurance for at least 63 days in the past year.

Call your insurer and tell them you had continuous / overlapping coverage, tell them their pre-existing status is bullshit, and that you'd be happy to call your lawyer if they don't fix this immediately.

The problem should not come up again after that.

 

[Kelemvor]

Yeah, what the guy above me said. Definitely clal and complain. And also find your state's insurance commissioner type person and complain to them as well.

Not pre-existing unless you go without insurance and then start it back up again.

 

[CptCrunch]

I work at a hospital and I hear this kind of stuff all the time. If there was a lapse in coverage, even for ONE DAY, and your new insurance policy has a Pre-Existing coverage clause, they can deny you coverage if this was a known issue before you signed on to the new insurance company.

If there was no documented cases, doctor visits, hospital visits, tests, etc that would signify an issue, then there is no pre-existing condition. Appeal, and if that fails, go to your local media. Send out a mass email to all of the news stations at the same time, giving your details and case and say, the first station that will pick up your story, you will give them an exclusive story. Media these days are all about the exclusive stories.

 

[PokerGuy]

Originally posted by: satyajitmenon

Originally posted by: tallest1

Originally posted by: gar3555

Originally posted by: spidey07
Important question, was there ever a point in time when your daughter had a lapse in insurance coverage? I'm confused. Did you move your wife/daughter to your insurance?

She had quit her job to be a stay at home mom, and her work insurance was expiring, so we switched.

Originally posted by: lykaon78
Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

1. Yes, with a switch of plans when my wife quit her job.
2. Not that anyone knew about.

If your appeal gets denied. I would sooo sue over that. All you gotta do is find one news station to listen to your story and the public will laugh at how stupid it is for one to claim that a baby has a pre-existing condition.

This. Besides that fact that it's laughable that they're claiming the baby has a pre-existing condition, if the child was on insurance from the day she was born and there was no break in coverage, I don't think they have grounds to deny.

Do you guys even read? The child was not covered from birth, so it's very much possible to have a pre-existing condition when the child was added to a new policy. The appeals process is slow, but it might work. They are claiming a pre-existing condition. The question is, is there any documentation of the condition existing prior to the new policy taking effect? Is there any medical indication of when the problem first started (not when it was diagnosed, but when it actually started)? That's what the appeal is going to be focused on.

 

[lykaon78]

Originally posted by: gar3555

Originally posted by: spidey07
Important question, was there ever a point in time when your daughter had a lapse in insurance coverage? I'm confused. Did you move your wife/daughter to your insurance?

She had quit her job to be a stay at home mom, and her work insurance was expiring, so we switched.

Originally posted by: lykaon78
Two important questions:
1. Has she been continually covered by insurance her whole life?
2. Did she have problems with her tear ducts before she was covered by your current insurance plan?

1. Yes, with a switch of plans when my wife quit her job.
2. Not that anyone knew about.

I work for an insurance company (life not health) and I know a little about contesting claims.

Question 1 is important because most states say that pre-existing conditions are null and void if you have continuous coverage. Those laws exist so that people changing jobs or employers changing insurers don't expose themselves or their employees to denials based on pre-existing conditions.

Even if question 1 does not apply to your situation, question 2 is your winning point. If your daughter did not develop this problem until after the effective date of your insurance then you'll win on appeal. If the appeal fails find out what documentation they have of her pre-existing condition. While initial claims are denied all the time, the appeals process almost certainly contains the thought process: 'If we deny again, will our denial stand up in court?" If they don't have adequate documentation you can throw around the term 'bad faith.' In most states you'll win punitive damages when you can make a claim and prove that the insurer denied the claim in "bad faith" or basically without a reasonable position from which to deny.

If the appeals process fails, get your state department of insurance involved. File a formal claim and that normally gets the attention of someone in a different department than the normal claim operations area. In my company the DOI complaints are handled in our compliance area whose main responsibility is to make sure we comply with all laws and maintain the integrity of our license.

I hope this helps.