We’re Your Health Insurance Company And We’re Here To Help …

Feb 8, 2013 by winjaw

That would be a “no.”

The role of a health insurance company is to deny any/all claims. They will not even acknowledge misstatements or lack of full disclosure by their own employees, even when said employees’ statements are heard by more than 20 witnesses.

Am I ranting? That would be a “yes”

Following is my “appeal” letter to my wonderful, most awesome, we’re here for you insurance company. Basically, I got hit with a nearly $900 bill for taking the SONs for an office visit, which I was assured would only be a $40 copay for each.

My heart goes out to people with serious illnesses who have to deal with these companies.

I’d put in their response, but the English version is “ha, ha, ha.” I’ve left out the names of the guilty and innocent.

 

Dear Appeals Department:

I am respectfully requesting a review and appeal of the charges I had to pay regarding my three sons’ visit to their doctor.

I have enclosed the bill, which totaled $884.52. (Exhibit A) I also have included EOBs from two of my sons.) (Exhibits B and C)

However, despite repeated requests, I have yet to receive, nor has he, the EOB for my eldest son, Caleb. Therefore, please excuse the delay in filing this because I was hoping to provide all information. However, after waiting this long, I have decided to go ahead and file.

The issue is over what your two staff said during their presentation about our new plan verses what more than 20 employees, including several award-winning journalists (myself included) heard and understood.

Our staff’s primary question, which was asked repeatedly, was whether we could continue to see our regular doctors. We were told repeatedly told that yes we could but there would be a co-payment.

So far, so good.

I took my three sons in for a pre-school checkup, a Boy Scout physical and shots for one of the boys. Imagine my surprise when I got a bill (Exhibit A) for $884.52. I thought I would be billed for $120 – three co-payments.

I immediately informed our HR director and she called your staff who made the presentation as well as our insurance reps. What we were told is that physicals require a $2,500 deductible to be met first – that they are not covered. And apparently, shots aren’t either.

I was the first employee to find out that basically, the only doctor visit that allows a copay is when the patient is sick. Everything else apparently requires meeting of the $2,500 deductible before XXXXX company kicks in 80 percent.

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The issue caused such an uproar that XXXXX had to send in two more staff to hear our complaints and go over the plan again.

Bottom line, no one at our company ever heard about all these restrictions. More than 20 people will tell you that we were flat out told any doctor visit to our own doctor required nothing more than a copay.

But it gets worse.

We have more than 20 people saying your staff told us doctor visits were a copay only.

Yet one of the documents your staff presented and handed out to us gives yet another and completely different statement. I refer you to Exhibit D, which says primary care visits under Tier 2 (which my doctor is) a $40 copay. Preventative services “plan pays 80%” There is no mention of meeting a deductible.

Then we have Exhibit E – part of the full plan coverage document. It states the primary care visits are a $40 copay. It also says “injection” visits are a $40 copay.

So, we have your staff saying one thing, we are given a document that says something else and we have a third document that says yet something other than all that.

One of my sons got injections – therefore based on your own documents he should only pay a copay of $40. Yet he was billed for the entire visit and injection.

My other two had routine doctor visits, but were charged full price and no copayment allowed. It all went to my deductible.

I am requesting that I be reimbursed for the charges relating to the bill enclosed as Exhibit A. I am more than willing to pay the copayments of $40 each and am even willing to pay an additional $40 copay for the injection visit.

I have already paid the bill and am therefore asking for reimbursement of $724.52 (The original $884.52 minus four copayments of $40)

Respectfully submitted,

John A. Winters

 

So, want to share your own horror story?