I chose not to carry insurance for one year, and then signed back up last year. My insurance company (a PPO) has denied *every* out of network claim I have submitted. They are denying my auto accident, my son's ear infection, my daughter's dislocated wrist, and my counseling on the premise that we cannot prove they are not pre-existing conditions.
They have now denied my claim for the birth of my latest child, despite the fact that I confirmed with my HR deparment prior to the birth that midwives would be covered, because the policy reads that "out of network practitioners must be 'licensed' to practice by the state." Texas doesn't "license" midwives, it "certifies" them.
I have two accounts in collection and have spent a ton of money out of pocket that has not beem reimbursed. At what point (if any) should I retain counsel?
[ July 19, 2004, 12:12 PM: Message edited by: Jim-Me ]
Posted by Farmgirl (Member # 5567) on :
What a sucky insurance company! I'm surprised your H.R. department isn't helping you more by advocating on your behalf.
FG
Posted by Jim-Me (Member # 6426) on :
according to the insurance company, my company is the one who directed them to do this.
My HR department has been, literally, unresponsive thus far.
Posted by Bokonon (Member # 480) on :
Get Michael Moore on the case.
No, seriously.
He got an HMO to pay for a life-saving organ transplant for a guy, after they refused it, essentially condemning the man to death. Nothing like inviting HMO executives to someone's funeral.
---
Honestly, I have no advice, except that I hope that everything gets resolved in your favor!
-Bok
Posted by Kwea (Member # 2199) on :
Sounds like you are screwed...
I would tell them that you ae pursunig legal options as of today if these claims aren't coverd. Mention the triple endemnity laws that most states have. If you can prove in court (which is hard to do) that these patterns exist and that they are discrimnatory then the HMO may have to give you triple the amount owed.
As far as the midwife, did you check with anyone at the HMO before the birth? If so, did you get a contact persons name? Or is there proof that you discussed it within your company? Without proof it is hard to convince a lawyer to even take the case.
Kwea
Posted by Jim-Me (Member # 6426) on :
I have the name of the person at my HR department who confirmed that midwifery was covered under our insurance, but I did not contact the PPO (different from an HMO in that they specifically cover out-of-network stuff without a referral).
I really find it hard to believe that I have to prove that injuries sustained in accidents are not "pre-existing conditions" in the absence of any evidence to the contrary. even if they were aggravating an earlier condition, it's clear that new trauma can't be pre-existing isn't it?
<very angry>
Posted by TMedina (Member # 6649) on :
Sorry Jim - I have no idea as to the legal wrangling.
But if you've exhausted all of your other options, ask HR if they can refer you to a good lawyer.
Even if they can't, that should get alarm bells ringing.
-Trevor
Posted by Dagonee (Member # 5818) on :
quote:At what point (if any) should I retain counsel?
When they said an auto-accident was pre-existing. Sounds like you need it now.
And it's never a good idea to tell someone you're considering legal options until you've spoken with your attorney. Once an attorney is representing you, let him handle communications (or tell you what to say).
Dagonee
Posted by Jim-Me (Member # 6426) on :
Sorry if I've sounded ungrateful here... I'm still upset and it's coloring my writing.
So, I want to make sure to say thanks to all for your help, advice, and commiseration, not to close the topic (because I still need information), but to let everyone know that I appreciate their responses.
Posted by Jim-Me (Member # 6426) on :
thanks, all. Posted by rivka (Member # 4859) on :
Dealing with recalcitrant insurance companies is AWFUL. Good luck, Jim-me!
Posted by Kwea (Member # 2199) on :
![[Smile]](smile.gif)