Have you challenged your insurance company and won?

[Life_is_Good]

Who hasn't received some type of insurance denial and figured you can't fight "the system"? I used to fall into this camp until I found that pushing the issue further began to get me results. Here's a few of my examples:

1) Being unhappy with one health insurer's rates ... wife and I applied to another major insurance carrier. We completed all the standard forms and medical releases. Several weeks later... we both received standard denial letters indicating our doctors had not sent in ALL of what they needed. I told the phone rep that we did out parts by taking the signed medical releases to the doctors office personally. I argued that if the underwriters needed some more specific information from our doctors..... well why don't they call them and get it rather than deny our application into the system. Fortunately, I must have spoken to a very competent phone rep who volunteered to follow up with our issue and agreed this wasn't our fault. A week later, we BOTH received acceptance letters into thier health plan.

2) Under one of our plans... some preventative services were covered without any out-of-pocket costs. However... in some of the small print... these services must all be completed within a limited number of office visits. My problem was that my Dr only performed some of the "well being" service in office and contracted out for others. After submitting the claims, several were denied because they counted as separate office visits, rather than simply as the preventative and fully covered procedures. Anyway... we sent in a written grievence addressing this issue. While they held firm to their policy guidelines and denied future preventative measures not falling within the office visit limitations.... they approved our claim and made an exception to pay us.

My lesson..... don't take NO for an answer if you feel you are in the right.

Anybody else challenge and win?

[Peaceful_Warrior]

We had a minor issue this year. After my son was born, the health insurance denied his hospital bill because 'Coverage was not in effect' at the time of the visit.

I later noticed that the system showed him as having coverage officially start on the day *after* his birth.

I called them up and explained the situation, and they adjusted his official coverage date to his birthday and pushed the claim through again.

[Caroline]

Years ago I had my wisdom teeth out. Insurance paid only a small part on the claim, saying that the cost was beyond the "ususal and customary."

Now, bear in mind that my teeth had been very impacted, that I'd woken up during the procedure to find the dentist working with hammer and chisel to get them out (I'd had laughing gas though, so I didn't care a bit), and that my entire face had swollen up for two weeks afterwards.

To add insult to injury, I'd sucked on a popsicle a few days later, which dyed my mouth orange and led my husband at the time to say that I looked exactly like a tropical fish.

I wrote a friendly and funny letter back to insurance with all of this information, including the tropical fish remark.

They paid it all.

[BUM]

I'm getting ready to battle the bastards tomorrow. No real biggie, but this this could be good training for me.

I recently went to see a neurologist I had seen a few years ago. His receptionist said they didn't take my insurance but they would submit a claim anyway and I should just pay the copay, and we'll see what happens.

Well Aetna denied the claim and it looks like I'm stuck with the $250 bill minus the copay. I pay about $400 per month (as a single) for this coverage

[mykidslovedogs]

Originally Posted by BUM

I'm getting ready to battle the bastards tomorrow. No real biggie, but this this could be good training for me.

I recently went to see a neurologist I had seen a few years ago. His receptionist said they didn't take my insurance but they would submit a claim anyway and I should just pay the copay, and we'll see what happens.

Well Aetna denied the claim and it looks like I'm stuck with the $250 bill minus the copay. I pay about $400 per month (as a single) for this coverage

On a PPO, "out of network" claims usually apply to the out of network deductible. If your plan has an out of network deductible, you are likely going to be responsible for the bill as per your contract with the insurance carrier. Do you have a copy of your contract? I would take a look at it before you make your appeal. You might be wasting your time. If it is an HMO, then it probably would have required prior authorization before visiting the specialist. Again, this would be per contract, so if you didn't get prior authorization, then you are probably going to be responsible for the bill. The premium you pay for your insurance is based on your current contract. I can't say this without sounding offensive, but, IMO, it is your personal responsibility to know your contract BEFORE seeking services. Knowing that your provider didn't take your insurance, you should have called in advance to find out what you could have expected with regards to coverage.

I don't understand why people automatically assume the insurance company and it's employees are "bastards" when people technically should have understood what they were buying when they bought it. When you bought that policy, and agreed to pay $400.00/month for it, I would be very surprised if the contract didn't specify that you were to use "in-network" providers and facilities in order to receive the best coverage. Most insurance companies do not provide "indemity" (any doctor) policies without charging a much higher premium.

It's usually pretty hard to get the insurance carrier to make an exception to the contract that specifically spells out how out of network services will be covered......Then again, I have made appeals before and have been successful, particularly if there were no "in-network" doctors in the servicing area that could provide the same services that you needed...