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Jacked Around By Aetna
Old 12-04-2011, 01:07 PM   #1
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Jacked Around By Aetna

In October, after having an individual Aetna health insurance policy, ($5,000 deductable no where near met for this year) that I bought through AARP (for people over 50), for 2.9 years, I had a basil cell carcinoma removed that the doctor billed (before negotiated fee), $2300. Negotiated fee is $1100.This was my first and only incident with basil cell. Aetna flagged the claim, "pending further infiormation." I called repeatedly to Aetna to find out what kind of information and received secretive, evasive, and contradictory information. On Nov 7 I had the doctor's office call Aetna, and as a result, the office sent Aetna my medical records. As of Friday Aetna states that they did not receive anything and continued to pend the claim. After more calls I finally talked to a claims specialist who - after more contradictory information - said, "oh, they're excluding the claim under the preexisting conditions exclusion because you didn't have health insurance when you applied to Aetna in 2008. You'll have to get affadavits and prove prior insurance coverage." After a lengthly discussion this person called my previous insurance company (coverage of which I declared when I applied to Aetna), and received verification that I did have coverage. She said I would hear "something" in 10 days. How can they call it a preexisting condition when:
1) They claim they've never received my medical records;
2) Therefore, they have no such evidence (besides the fact that it doesn't exist).
Has anyone else had this kind of problem with Aetna?
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Old 12-04-2011, 05:25 PM   #2
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I have not had a lot of problems with Aetna through the years, but I was with a group plan. Just a guess here, but i'll bet they're jerking you around because you are on an individual plan. My daughter is with a group plan with a small company (20+ people) that she manages for the company among other duties. After two years of hassles, she's working hard to change insurance away from Aetna to Universal Healthcare. She tells me that Aetna is a constant aggravation. And there are medical offices in our town that will not accept Aetna for payment. You have to pay them yourself and submit it to Aetna yourself. Good luck on your claim.
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Old 12-04-2011, 05:33 PM   #3
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SkisALot: If this is really irksome to you, contact your state insurance commissioner's office. They can provide you with guidance on how to move forward.
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Old 12-04-2011, 06:15 PM   #4
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Since my earlier post here, I've done some research and found that Aetna is doing to many others throughout the country (on both group and individual plans) the same things they're doing to me. It appears to be widely known, but this is my first experience with them.
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Old 12-04-2011, 06:22 PM   #5
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Customer (Non-)Service. Not a way to run a successful business. My wife had Universal Healthcare during her cancer treatment and was quite happy with the customer service.
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Old 12-05-2011, 06:17 AM   #6
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I changed my auto / home insurance last January and a couple of months ago got a notice that I was being canceled for not paying an extra $500 owed because I had not provided proof of prior insurance. I straightened that out (error on their part), then more recently, they said I had not provided proof that my medical insurance was primary to the auto insurance. This proof was never requested when I took out the policy.

My take is that the insurance companies are going back over all the policies with a fine tooth comb to squeeze more profit.
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Old 12-05-2011, 09:26 AM   #7
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Originally Posted by travelover View Post
I changed my auto / home insurance last January and a couple of months ago got a notice that I was being canceled for not paying an extra $500 owed because I had not provided proof of prior insurance. I straightened that out (error on their part), then more recently, they said I had not provided proof that my medical insurance was primary to the auto insurance. This proof was never requested when I took out the policy.

My take is that the insurance companies are going back over all the policies with a fine tooth comb to squeeze more profit.
Some seem to think that this is merely a 'customer service' problem, but in fact this is a known process generally referred to as 'post-claim underwriting' or 'rescission.' It was highlighted in Michael Moore's film "Sicko."

Never forget that insurance companies are for-profit corporations...
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Old 12-05-2011, 11:08 AM   #8
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In Calif. insurance companies supposedly only have 2 years from the date of application to "post claim underwrite," but obviously, the insurance commissioner isn't willing to do anything about the companies who are doing it. Demanding that a person show proof of prior insurance is illegal after this recission period; the insurance company should have done it at the time of application and they are not suppose to be able to go back because they didn't do their jobs.
DH had signed up for an Aetna Medicare Part D plan, but this morning he dumped it and went to another company that has a good reputation. I wish it were that easy for me but I'm going to give it a try. Is there a company you Californians have had good luck with?
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Old 12-06-2011, 07:51 AM   #9
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BTW: I found this to be a good source of info about health insurance: Health Insurance, Affordable Health Insurance Plans | Health Insurance Quotes

TJ
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Old 12-06-2011, 08:27 AM   #10
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Sounds like whoever you talked to is an idiot. They have a 12-month wait on pre-existing conditions for those with no prior coverage, but that would have expired anyway by now even if the condition existed at the time. Ask to have it escalated to a supervisor. Do you have an agent? If so, ask the agent for help.
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Old 12-06-2011, 02:00 PM   #11
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Sounds like whoever you talked to is an idiot. They have a 12-month wait on pre-existing conditions for those with no prior coverage, but that would have expired anyway by now even if the condition existed at the time. Ask to have it escalated to a supervisor. Do you have an agent? If so, ask the agent for help.
This is slightly off center to this thread, but I would definitely recomend dealing through a broker, not directly with an insurance company when you are shipping for insurance, even Medicare supplements or Medicare Advantage. You still want to do your own homework, and at times the agent may have a misunderstanding, but he has more resources available to him than you as an individual have. Best of all, it costs you nothing extra, at least in the Medicare space.

In my budget, housing is 1st (I have been renting), but food and Medical spending are tied for second-and I have not been sick- just premiums do it. So while Medicare helps, don't look for a huge benefit from this, even at today's arangement which I anticipate will get worse over time.

Be informed as best you can, and to paraphrase the immortal words of our dearly beloved Uncle M, it's better to piss on than to be pissed upon.

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Old 12-07-2011, 04:32 PM   #12
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Sounds like whoever you talked to is an idiot. They have a 12-month wait on pre-existing conditions for those with no prior coverage, but that would have expired anyway by now even if the condition existed at the time. Ask to have it escalated to a supervisor. Do you have an agent? If so, ask the agent for help.
I've talked to a lot of idiots there; in fact I've yet to talk to anyone who isn't one. (They've also hung up on me.) I believe that idiocy starts at the top. And no, I don't have an agent; I bought the policy on my own. But I won't make that mistake again.
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Old 12-07-2011, 04:35 PM   #13
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I believe that idiocy starts at the top.
No doubt about that.
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Old 12-08-2011, 12:26 PM   #14
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Originally Posted by Gotadimple View Post
SkisALot: If this is really irksome to you, contact your state insurance commissioner's office. They can provide you with guidance on how to move forward.
+1

In my experience and that of my friends, few health insurance companies will pay a claim on the first round. But if you're persistent they will probably eventually pay, if you're entitled to it.
I suggest you keep careful records of your every interaction with them.
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Old 12-08-2011, 12:32 PM   #15
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Originally Posted by toofrugalformycat

+1

In my experience and that of my friends, few health insurance companies will pay a claim on the first round. But if you're persistent they will probably eventually pay, if you're entitled to it.
I suggest you keep careful records of your every interaction with them.
That is good advise that I need to remember. My individual carrier has been perfect so far in the 18 months I have had it. Perfect in they have successfully cashed every premium check I have sent them on time. I havent asked for anything in return yet, so I need to be prepared for the worst in case it would ever happen.
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Old 12-08-2011, 01:19 PM   #16
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Originally Posted by toofrugalformycat

+1

In my experience and that of my friends, few health insurance companies will pay a claim on the first round. But if you're persistent they will probably eventually pay, if you're entitled to it.
I suggest you keep careful records of your every interaction with them.
+2

Track EVERYTHING. Keep a list of interesting addresses for escalation, including the appropriate state insurance commission complaint office, and the office of the CEO and perhaps VP of Consumer Affairs at the insurance company. Keep copies of all correspondence sent and received. (I scan everything into a computer, with a separate folder per claim.)

Once an initial claim is denied, start sending responses in a trackable form, such as certified mail with return receipt. (And scan in the post office receipt and return receipt once you get it!).

After a second denial, I generally escalate, sending responses and a copy of all previous correspondence to the claim processor, CCed to the CEO office and so noted on the cover letter. If it is a really egregious denial, violating state law or regulations (which the OP's insurer appears to be doing), I also bring in the state insurance commissioner at this point. The goal is to make the denial more expensive than just paying the claim, through involving more of the insurers staff, and possibly requiring them to make (expensive) responses to the state office.

It's a pain in the a$$, but it sometimes may be necessary with an overly enthusiastic loss mitigation specialist handling you initial claim.
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Old 12-08-2011, 03:53 PM   #17
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+1 on at some point that you are not making progress to send a letter to the CEO. I used to work for an insurer (life, not health) and every complaint to the Prez or CEO was logged and got expedited treatment. Not sure if other insurers do the same but I believe many do.
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