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Vanity: Question re: fighting an insurance denial

Posted on 01/10/2014 11:47:53 AM PST by CheathamCountyTN

Need freeper advice: A close friend had serious female issues 10 - 12 years ago. The issues improved and she has only had 1 doc visit related to her problems in the last 5 years and that was 3 1/2 years ago. Wanting to avoid Obamacare, she bought a private Humana health insurance policy early last fall...


TOPICS: Your Opinion/Questions
KEYWORDS: denial; insurance; preexisting
During a 3 hour application "interview", she revealed all the above information. Humana also inspected her health records. She was approved with no exclusions. On the day her policy went into effect, she had a medical emergency (24 hours of vomiting and intense abdominal pain). Three weeks later, after exploring everything available to relieve her, she underwent surgery. The underlying problem was a massive e-coli infection in her abdomen. The doctors do not know where this infection began or how it began. It's possible it was related to her prior issues but it's also possible it wasn't. Because the infection had spread to massive proportions and she was near death, they did a hysterectomy as well as removal of the infection. Humana has decided to deny her $70,000 in claims because they contend that it's all connected to her past issues which is "possible" but not proven and apparently can't be. Does this sound like a fight she could win if she chooses to fight? She's a single woman, age 37, never married. The last thing she wanted was a hysterectomy. I would appreciate any thoughts or comments...
1 posted on 01/10/2014 11:47:53 AM PST by CheathamCountyTN
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To: CheathamCountyTN

A bacterial infection is not a long term illness. She may have to hire a lawyer to get the insurance company to pay.


2 posted on 01/10/2014 11:50:44 AM PST by Blood of Tyrants (The War on Drugs has been used as an excuse to steal your rights. Support an end to the WOD now.)
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To: CheathamCountyTN
RE :”Humana has decided to deny her $70,000 in claims because they contend that it's all connected to her past issues which is “possible” but not proven and apparently can't be. Does this sound like a fight she could win if she chooses to fight? She's a single woman, age 37, never married. The last thing she wanted was a hysterectomy. I would appreciate any thoughts or comments... “

That sounds illegal under Obamacare

If you fight them and win you can write a letter to Obama thanking him :)

Obama said they wont fine companies for doing this to you for existing policies but it seems like you can sue because its against the law now. Consult with a lawyer.

3 posted on 01/10/2014 11:55:56 AM PST by sickoflibs (Obama : 'If you like your Doctor you can keep him, PERIOD! Don't believe the GOPs warnings')
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To: Blood of Tyrants
A bacterial infection is not a long term illness. She may have to hire a lawyer to get the insurance company to pay.

Exactly. The bacterial infection was a medical emergency and was not a pre-existing condition. She would almost certainly win with a capable lawyer on her side. Humana might back down if she warns them that she is getting a good lawyer specializing in malpractice and will fight for as long as it takes to recover at least medical costs and legal fees, and if she throws in the possibility of punitive damages if their intransigence becomes a major life issue for her.

4 posted on 01/10/2014 11:56:59 AM PST by Pollster1 ("Shall not be infringed" is unambiguous.)
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To: CheathamCountyTN

I suspect she’s not telling you something. The timing sounds awfully coincidental.


5 posted on 01/10/2014 11:57:27 AM PST by AppyPappy (Obama: What did I not know and when did I not know it?)
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To: CheathamCountyTN
In some (maybe most?) states, the law allows for people to recover their legal fees from the insurance company in cases involving denial of claims. This is a good thing if your friend has to take legal action against the insurance company.

I would definitely advise her to speak with a good attorney who specializes in this sort of thing. Depending on the facts of her case, the attorney may be willing to take the case on a contingency basis -- which means your friend wouldn't have to pay the legal fees out of her own pocket.

6 posted on 01/10/2014 11:57:58 AM PST by Alberta's Child ("I've never seen such a conclave of minstrels in my life.")
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To: CheathamCountyTN
She needs to read (or let you) her policy. It would have to have an exclusion rider in it, that states that certain care or illnesses/issues would be excluded from coverage. If the policy was issued with an exclusion for gynelogical issues, for example, and she accepted the policy and signed papers saying she accepted it with the exclusion, she will have a tough time appealing the claim.

If she meet in person with an agent, who did not disclose that the issues might be excluded, she might be able to sue by going after the agent and insurance company.

If nothing else, and regardless of the above 2 considerations, she should call to the insurance commissioner's office for her state, and tell them her situation, ask if they have any advice or recommendations.

7 posted on 01/10/2014 11:58:52 AM PST by NEMDF
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To: CheathamCountyTN

Another thing she might look into, is to try to establish that the e-coli infection was NOT caused by the prior female health issues. Possibly she could contact ? the county health department or some germ-specialists at a local university to ask about what would be needed to follow such a path.


8 posted on 01/10/2014 12:01:21 PM PST by NEMDF
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To: CheathamCountyTN

How did she reveal the information of her past history? Is it in writing?

I’m not in the health insurance business, so I don’t know if the health contract might include any disclaimers for pre-existing conditions, even those disclosed.

Wait until the company gives the reasons in writing.

Even though it seems like your sister should be completely covered, it looks like it’s going to take an attorney writing a threatening letter at minimum. Chose someone who specializes in health insurance related issues.


9 posted on 01/10/2014 12:01:35 PM PST by Balding_Eagle (Damn ObamaCare, full speed ahead!)
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To: CheathamCountyTN

A legal consultation is in order. But it generally takes $5,000 down and $500/hour to operate the legal system. Insurance companies know this so it’s easy to deny a large claim and not risk a suit. She should start by enquiring of everybody medical she knows what options might be available. Start by plugging this into Google. “Humana denying claims.” That generated a LOT of hits and articles.

Good luck to her.


10 posted on 01/10/2014 12:06:36 PM PST by Gen.Blather
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To: CheathamCountyTN

Appeal it. And do it quick. If her policy was like mine, you have only a short time period in which to appeal. Get a lawyer and arrange a meeting with them. In my case they were bluffing, and payed the day before the scheduled meeting. Good luck.


11 posted on 01/10/2014 12:16:52 PM PST by deweyfrank
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To: sickoflibs
That sounds illegal under Obamacare

The original poster said that the friend had tried to "avoid Obamacare" - it's possible this is not an ACA-compliant plan, which may (I'm not sure) allow the insurer to deny based on pre-existing conditions.

12 posted on 01/10/2014 12:21:49 PM PST by Conscience of a Conservative
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To: CheathamCountyTN

Not knowing anything else about it I would say to first follow the policy proscribed appeal process. Just in my 13 person office myself and two others have had insurance denials that were later approved without any lawyers involved. I believe the ins. companies are quick to deny claims becuase it doesn’t cost them anything to string you along but if you have a legit case they will pay in the end.


13 posted on 01/10/2014 12:28:30 PM PST by RightOnTheBorder
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To: CheathamCountyTN

All I can tell you is what worked for hubby. After being denied denied denied his doctor personally called the insurance company and talked to someone higher up in the chain and told them........when mr. sheana sues you, which he is going to, I will be on the stand and testify for him. Approve approve approve. Within a couple of days.


14 posted on 01/10/2014 12:30:07 PM PST by sheana
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To: Conscience of a Conservative
RE :”The original poster said that the friend had tried to “avoid Obamacare” - it's possible this is not an ACA-compliant plan, which may (I'm not sure) allow the insurer to deny based on pre-existing conditions. “

That was my assumption but if the waiver for those is just Obama saying they will not fine those companies, its possible that the law is written such that he cannot legally allow the company to do that.

IN other words just because the IRS doesn't bfine the insurance company doesn't mean he cant sue them for violating that law, to get that $$$.

I think I saw George Will point this out first.

15 posted on 01/10/2014 12:31:04 PM PST by sickoflibs (Obama : 'If you like your Doctor you can keep him, PERIOD! Don't believe the GOPs warnings')
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To: CheathamCountyTN

She developed vomiting 24 hours before her insurance policy started? They could be denying it because it was a preexisiting condition- it started a day before her insurance was in effect. She needs an attorney to review this case, if she cannot afford it, ask the insurance commissioner in her state to look at the issue.


16 posted on 01/10/2014 2:25:44 PM PST by kaila
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To: AppyPappy

She knows how suspicious the timing looks but she had been vomiting for 24 hours when she went to the doc. She had pain in her abdomen too. This woman is a devout Christian, she was still hoping to marry and have children. The last thing she wanted was a hysterectomy. She had had no issues the last 3.5 years so, even though it might look suspicious, it really was an unlucky coincidence.


17 posted on 01/10/2014 2:38:19 PM PST by CheathamCountyTN
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To: Balding_Eagle

Her application “interview” was 3 hours long and it was taped by Humana so they have her own words and declaration that it had been 3.5 years at least since she’d been to the doctor. She even asked them in the interview if she needed to go back beyond 5 years and they told her they would be looking at her health records so they would know her whole story.


18 posted on 01/10/2014 2:41:22 PM PST by CheathamCountyTN
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To: Conscience of a Conservative

The pre-existing condition part of ObamaCare went into effect on January 1, 2014. All of this happened between October and December last fall. I think Humana is in the clear on being able to do this for services last fall. Unfortunately.


19 posted on 01/10/2014 2:43:33 PM PST by CheathamCountyTN
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To: Conscience of a Conservative
it's possible this is not an ACA-compliant plan

I think that also. A policy purchased independent of an exchange. Buyer beware. She should get a "patient advocate" to negotiate the charges down, otherwise if she can't pay it might be declare bankruptcy time.

20 posted on 01/10/2014 2:52:26 PM PST by steve86 (Some things aren't really true but you wouldn't be half surprised if they were.)
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To: CheathamCountyTN
All of this happened between October and December last fall.

OK, people assumed this had just happened.

So the policy went into effect prior to January 1st.

Not a good outlook for legal action, other than bankruptcy.

But still have her find a good advocate.

21 posted on 01/10/2014 2:57:05 PM PST by steve86 (Some things aren't really true but you wouldn't be half surprised if they were.)
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To: CheathamCountyTN

From your description it is certain she contracted the infection before the policy went into effect, unfortunately.


22 posted on 01/10/2014 3:01:53 PM PST by steve86 (Some things aren't really true but you wouldn't be half surprised if they were.)
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To: CheathamCountyTN

I think the problem they’re having is with the reason a hysterectomy was performed if the admitting diagnosis was a bacterial infection inside the gut. That’s something for the doctor to explain to insurance in the appeal. They’re seeing it as someone getting rear ended and claiming to need a new headlight.


23 posted on 01/10/2014 3:14:06 PM PST by ToastedHead
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To: ToastedHead

All they knew when she was rolled into the operating room was that she had a major infection somewhere..probably in her belly since that was where the pain was. I asked her if she knew whether the docs could have gotten the infection out (her belly was FULL of pus..docs said they had NEVER seen anything like it on a live person)without doing the hysterectomy but she wasn’t sure. The infection was in her fallopian tubes as well as everywhere else in her abdomen. This was a BIG emergency situation.


24 posted on 01/10/2014 6:35:59 PM PST by CheathamCountyTN
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To: CheathamCountyTN

It sounds like a medical coding thing. That’s not my line of business, but as long as the hospital records show an immediate need for removal of the uterus and related girly parts, it shouldn’t be too hard to appeal. It’s not like it was a face lift thrown in on a claim. Most importantly, glad she’s ok.


25 posted on 01/10/2014 6:44:00 PM PST by ToastedHead
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To: CheathamCountyTN

So if you have cancer but don’t know it and you go to the doc the same day your insurance policy goes into effect and, after 3 weeks of testing and searching for a cause for your symptoms, you’re diagnosed with cancer, that’s considered pre-existing? How could she have known she had an infection like that if she had no symptoms? Seems like if the illness reared its ugly head on the day the policy goes into effect, that’s an unlucky coincidence for the insurance company.


26 posted on 01/10/2014 6:44:34 PM PST by CheathamCountyTN
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