Got some very bad news

Well I just talked to my doctor and my insurance is refusing to pay for the surgery. I am sitting here bawling my eyes out and I don't know what to do. We can't afford to pay for the surgery any other way. It was going to cost enough just with the deductible and the remaining 20% so I just don't know what to do.

I have tried to reach the insurance company but haven't been successful yet. I plan on fighting this but I fear I will lose. I just don't know what to do. I can't go on like this. I really need this surgery. I need some relief.

Why is that we pay BIG insurance premiums only to be told that they won't pay for something that the doctor says is medically necessary? I just don't get it.

Insurance is such a rip-off.

Why are your insurance refusing to pay for the bill? Who is your insurance company?

<oops, insurance co names are not allowed> and let me tell you they are awful! They haven't paid for anything since I have had them.........meds, office visits, nothing.

They are saying that my condition is pre-existing and they won't cover it. But my doctor said she told them that yes, the fibroids may be pre-existing but the bleeding and pain are not. That is new and therefore is grounds for this surgery but they are being pains and still say no.

My doctor said she has never in all her years practicing had this problem before getting something ok'd and she is just shocked. So I guess unless I can get someone who has some compassion for someone in constant pain I won't be getting the surgery.

That is just nonsense. I would drop them. Sound like they are just being cheap. You should fight it. Maybe you should go in to ER with pains and have your doctor say you need emergency surgery.

Hi Sweetie,
I'm sorry that your having problems with insurance. You need to be persistant in trying to talk with your insurance co.If you are not getting anywhere with the person you talk to, then ask to speak to the supervisor. Perhaps the Dr can rewrite why you need surgery that doesn't show the previous condition.It's unfortunate that we need to "bend" the rules to get what we need. I work for a dentist and I go back and forth with some ins companies all the time. Sometimes all it takes is a little rewording in to predetermination to get something approved that was previously turned down. Anyway, I'll keep you in my prayers that you will get your much needed approval.
God Bless
Pat
TAH 09/17/04

File a written appeal, supported by a note or letter from your Dr.

needsomerelief,,,,,,
I have the same insurance and they paid without any percertification at all if I was to be in the hospital less than 24 hours..............and the codes used for a vaginal hyster calls for an out patient stay 23 hour observation............keep calling...call your doctor and talk to them.............Is your surgery a abdominal?????????? I know thats a longer stay so that may pose a problem....But if your a candidate for a vaginal hyster you may check out that option with your doctor.........But I do have the same insurance company and I didn't pay 1 red cent...........


Best wishes

Hi Sweetie. I can't imagine...good grief!

How long have you been with this insurance company? There is a limit to "pre-existing" condition. I think there is a 12-month limit on how long they can refuse to pay for treatment, and if you were covered by a different insurance directly before you joined this insurance, usually they will waive the waiting period.

I would call and make them talk to you...not the dr's office. Then you are more than a preauth number. Make them tell you WHY they are denying it. Also, is it an emergency-type surgery? Why did your dr's office cut it so close to surgery date before preauthorizing your surgery? Or is this a repeated attempt?

Who knows how long your fibroids have been around? Could be since puberty! If the symptoms are new, and that is the reason for the surgery, then it should be a no-brainer. Good grief...if you went in for your first physical in three years and they found you had high blood pressure, would they not treat it because it likely existed the three years before when you happend to be with another carrier? I doubt it. Who of us gets sick in the doctor's waiting room? So really all of our conditions are "pre-existing".

Sorry this is so long, but I get so mad how insurance companies add so much stress to an already stressful situation. They are obviously looking out for their bottom line, but what about our bottom lines when we look at our paystub each pay period and see the astronomical sum that they deduct for their "service". Then for them not to provide their "services" when it is needed is unacceptable. This is not an experimental treatment. It is a common procedure.

Definately fight it. Have your doctor fight it. Have him do two D&Cs after anesthesia and before hyster (just kidding!!!) You have a right to receive the treatment that you require and have it paid for by the policy that you have. Changing ins co right now would make it worse, but I would look into it after your recovery.

Good luck, my dear!

I also have <oops, insurance company names are not allowed> and had no problem with them pre-certifying or payment.

When it comes to pre-ex, if you have been TREATED for any signs or symptoms within the past 12 months, it is indeed pre-ex. BUT If you have not had a break in coverage for more othan 63 days, they cannot subject you to pre-ex. This means if you had other insurance prior to this carrier. The way to appeal is by getting ALL dr. records to show the date of initial treatment. If the initial date of treatment is AFTER your insurance became effective, the appeal will be approved. Worst case scenario, once the plan has been in effect 12 months, it would be covered.

I don't know if your plan is an individual plan or a company sponsored plan, if its company sponsored, contact your HR/Benefits Rep for help.

Good Luck.

09-15-2004 10:59 AM

LOL I see I'm not the only one here who can't seem to get up from this chair....guess I need you all more than I knew....after seeing some of the posts before about insurance problems...I called mine to see about the verification of it all...I used to do insurance so I know all the problems that can arise...well they informed me that yes I was in their computer for the 17th and was due to be hospitalized...now get this! from Sept 17th through the 18th!! Excuse me I said...she said yes thats what I see...are they kidding?? sooo I called my doc;s office and she is checking into it....yea OK I'll just get up and go home in the morning following surgery...me stressed?? nahhhhh lol I know how many mistakes are made when dealing with insurance companies...so I am trying to not freak out until I hear back....