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insurance woes

jbeardslee's picture
Posts: 76
Joined: Jul 2001

Hi....Hope this finds everyone doing well. I know my problem is not as critical as some but none the less, I'm looking for advice. Our primary health insurer is denying my claims; they are trying to prove a pre-existing condition. They haven't paid anything, not the annual mammogram, lumpectomy, mastectomy or the colonoscopy so the bills are mounting up. I have filed an appeal but they have until Jan 11th to decide. I sent the annual letters from my doctors and the radiologists that all my mammograms were considered normal as part of my appeal. I even had our attorney call them and the surgeon!! With the denial letter, the ins company also sent a waiver for us to sign relieving them of all claims pertaining to any breast disease in either breast or complications thereof. The waiver had to be returned by Sept. 21st or they were going to cancel insurance not only on me but my husband and daughter as well. Even the attorney couldn't get us an extension on the deadline. Now that they have the waiver, what are the chances they'll pay anything? I doubt they will but haven't given up hope. If they deny this appeal, I am entitled to a 2nd. And in fact have to go thru that process before I could file a law suit. I have reported the company to our local Representative, The State Insurance Commissioner and I'm in the process of filing a complaint with our State Attorney General. Nothing budges these people. The Ins. Commissioner's office only has jurisdiction over whether the claim is paid according to the policy, not whether there where circumstances that put the coverage null and void.
Thanks for listening. I feel better just knowing I have a place to come and join with all of you. You are a great group!
love, judy

Posts: 682
Joined: Feb 2001

Hi Judy,

I'm sorry for your insurance problems which seem unsolvable but I hope WILL be solved.I'm wondering what state you live in and what the insurance is. We would all want to avoid thatcompany.
How weird - cancer is always pre-existing until it is found - apparently you were not with them a long time.

I feel like a Pollyanna these days and therefore say: It's good that you did not need chemotherapy because that is really expensive - especially the taxol - and radiation too.

Good luck Judy - try not to let this affect your daily routine and future health. Will keep you in my thoughts and prayers.


Posts: 706
Joined: Jul 2001

Hi Judy:

I'm so sorry for what you're going through with your insurer. It's amazing what some companies will stoop to in order to avoid paying legitimate claims!

Each state is different in what assistance they offer in these matters. In many states,
the Insurance Commission is able to contact the insurer directly, and get something definitive within 30 days. Also, it doesn't sound legally kosher that they could even consider canceling coverage on your husband and daughter! What justification could they have? I'm curious as to how long you were insured with them before your diagnosis? Some companies have a 90 day waiting period before they'll consider conditions not to be pre-existing. But they all seem to be different in their requirements, again, depending upon which state you live in and it's governing laws.

If your state's Insurance Commission is a strong, pro-active one, then you should get some good results through them. Keep on them and request updates of what they're doing, etc. and request copies of their actions on your behalf.

Just when we're least able to cope with these kinds of difficulties, it seems that they hit us the hardest! You're in my thoughts. Hang in and hang tough!!!

Love, light and laughter,

jbeardslee's picture
Posts: 76
Joined: Jul 2001

Hi....me again. We live in Penna. but the ins company's base address is Green Bay, WI. At least that's the address for appeals. :)
We are self-employed and after several premium increases thru Aetna, we started ins. shopping. We applied at American Medical Security and it was 2 months before they wrote us the policy. So it's not like they hadn't done their homework. We did have the ins less than a year; that's why I didn't know they wouldn't pay for the mammogram. This was an annual check-up, not a mid-year exam because I suspected any problems. As for the grounds to cancel us with-out the signed waiver, I don't know how they could do that either. But I know our attorney was convinced after speaking with them on the phone. He asked if they realized what they were asking us to sign, and they did. He was stern but calm with them, still got no where. The insurance Commissioner has assigned a lady to my complaint; I hoped that was good. However on the phone she was quick to point out her jurisidiction and also that if we were cancelled, she could not help us get re-instated. As for the pre-exisiting condition, the quetion they asked on the app was if any one of us had received treatment, diagnosis, therapy, counseling or medication for ........56 different conditions. The one they are complaining about was breat/implants. I answered 'no'. They're allowing the our attorney that because I had had anuual mammograms, possibly that can be construed as diagnostic. A major factor is going to be that I did have calcifications for a number of years. These however were only pointed out on the radiology reports that became part of my history. Even though I had mammos under different doctors over the years, non thought the calcifications were abnormal or considered them to be anything leading up to cancer, so I never was told about them. However, once the claims started the ins acquired the radiology reports and BINGO. I wish they had seen them during that 2-month period they were checking us out, then maybe we would have ended up with ins someplace else.
and if they want to get real technical, my cancer was not found in fact in the calcifications, but in some bordering tissue. I'm blessed that it was found and taken care before it spread. I thank the Lord for that daily, the bills will get taken care of one way or another.

Thanks again.
love, judy

pamtriggs's picture
Posts: 407
Joined: Sep 2000

Dear Judy
What a lot of bastards insurance companies are (excuse the language). They are gambling we live & we are gambling we die when you think about it. It seems they are a lot tougher about paying claims in US than here in NZ. MY insurance company accepted my pre-existing condition of a trouble free mastectomy 20 years ago when we changed insurance companies 10 years ago as my husband's company pays the premiums as part of a group scheme & it was one of the scheme conditions or my husbands employer would not go along with them. So they had to pay & boy have they paid with all the chemo & hormones & diagnostic tests I have had. I can do nothing to help or advise you except to hang on in there with them as long as you are able to fight them. FOr everytime they get away with it it makes it easier for them to turn us down when we really need all the support we can get. I am thinking of you. Lots of Love. Pam

Posts: 1416
Joined: Mar 2001

How is it that an ins. company can deny a claim on these grounds. What about genetics and what about the fact we are talking about cells. I never had my life insurance altered because of my disease, I just can't afford to buy any more. Isn't it funny the ins. companies tell us we are not permanently disabled, since cancer is a curable disease in their black book. Yet deny claims because they believe it was a preconsisting condition. What will be next, doctors denying treatments because they can't tell if their is a cell still left to grow???
I am so sorry you have these worries on top of your health. It is through things like this that make us stronger and better able to meet challenges head on. Maybe you will go after your company to change things for the next person to follow your same path.

Posts: 58
Joined: Jun 2001

Hi Judy,
I know first hand how stressful it can be dealing with insurance companies. First of all remember that your the consumer and they are providing a service to you. If your having a problem ....i dont know what state your in .... but file a consumer protection report with your Attorney Generals Office. That kinda lets you off the handle and lets the AGs office see where the problem is but dealing one on one with the insurance company. Read up on your policy starting with the year of your needs. They do have the right to deny overbilling and have certain other factors they may not have to pay ...however, if youve met your deductable and have obtained certain precertification for things specified then i certainly would move to the next level.
I KNOW HOW STRESSFUL it is and how it hinders your healing process ...been there done that. Just take your time and DONT sign a release with them....BIG mistake there if your in the appeal process anyway. I have more info if you want to tell me what state your in i can look it up for you. Ill be glad to help in anyway i can.


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