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Anyone had to fight with the insurance company?
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03-11-2006, 10:06 PM
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Guest
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Posts: 46
Hysterectomy: March 22nd, 2006
Surgery Type: TAH
Ovaries: Undecided
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ins.
[font=Times New Roman][color=RoyalBlue]Thank you so much for your responce I will look into that. I am just so frusterated that I do have ins, and they do not want to pay, I am in the middle of an appeal with the dr. going to fight this all the way, i pay alot of money for the ins that I have to be denied for something that is not true (pre-x cond). Thank you again. very good to know that someone is out there to help.
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03-13-2006, 09:38 AM
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HysterSister
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Posts: 390
Hysterectomy: September 19th, 2008
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Anyone had to fight with the insurance company?
Only question I have for you 4sweetpeas is were you diagnosed with your condition in the past 5 years by a doctor? If so, you may have to do what Weiser suggested or do like I have to do and wait out the waiting period until the insurance company has to approve. How long is your waiting period? The most that insurance companies can impose is 12 months (AFAIK), so I'm confused that you'd have to wait until May 2007??? That's like 15 months away? I'd look into that again if I were you. Make sure you check your state private insurance laws.
In my case, I am dealing with two issues - the first is tests (pelvis U/S, hysteroscopy, endometrial biopsy) that have already been done - will the insurance company pay or not? All is still under investigation. Second issue is upcoming breast biopsy for microcalcification clusters that are not palpable. I am not so sure what will happen with the first issue, but the second issue I do feel more confident that the insurance company will pay up. The burden is on the insurance company to prove that the condition was never diagnosed. If indeed it was never diagnosed, then the insurance company has to prove that I had symptoms for which a "reasonable person" would have sought medical attention. Obviously, microcalcifications are something that cannot be felt and produce no symptoms - that's why we have mammograms! - so I think the insurance company would have a difficult time claiming that one to be pre-existing.
The only thing I've learned - and I've really scoured the internet for info - is to do the following:
Be a broken record and tell your doctor's office that you do not have a pre-existing condition, that it was never diagnosed before, and therefore the insurance company is to pay the bill. The doctor's office doesn't care who they get the money from, they just want to get paid, so if you make it clear that the money will NOT be coming from you, they will make a greater effort to get it from the insurance company.
If the doctor's office is unsuccessful, then the next step is to appeal with the insurance company. With my insurance, there are 2 levels of appeals.
If the appeals do not go your way, then the last step is to appeal with your State Dept. of Insurance.
The only bright side of this process is that at least while everything is being appealed, the bills are on hold, and that buys time to save some money.
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03-15-2006, 02:20 PM
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Guest
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Posts: 77
Hysterectomy: November 9th, 2005
Surgery Type: SAH
Ovaries: Removed both
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Stress
When my husband was in Intensive Care
Unit (ICU) for 5 days, we too got a huge
run-a-round headache from our Ins. co.
(non-PPO / in house/out of house dedcutables)
above ususal & customary expenses, well
you get the point. We ended up paying right
at 3/4 of the total bill ~ one pay's their preimums
diligently through-out our lifetime (23 years)
then to make a claim, thinking your "covered"
come to find out, your trusty ins. co jumps
thru every hoop to get out of paying?
We did take it thru court, they ended up
paying 1,100 more on the bill, but that of
course was eaten up by lawyer fee's.
only to raise our premiums to $1224 monthy?
We soon thereafter canceled out our policy.
Insurance issues are only 1 of the
many reason's my husband & I flew
to India to have my hysterectomy
($2,357 dollars total bill for all)
total less than 2 months of ins. premiums!
put the charges on our Credit Card
and paid it upon return to the states.
3rd leading hospital in the WORLD
(behind Mayo Clinic) 10 day "in deluxe
suite" included a complete mamogramm
& total health check including a complete
colonostomy & prostrate for husband.
(google research medical tourisim)
We had the best care ever experienced
over our entrie lifetime, while in India,
My surgeon gave me his "private cell
and home phone numbers" No need for
either pain medication or antibiotics/EVER.
In fact, my recovery was well attended
by the groups top medical team ~
I've never felt sooo cared for in my life!
I'm all healed up and feel absolutely great.
4 months post-op and I'm already back
to riding /showing horses again!
Will we return to India? You bet we will...
planning on it this fall for dental work
(crownes $ 80 bucks/eye surgery $ 400)
I can't wait to return ~ the people are so
kind, helpful, caring & loving individuals.
God Bless
Ronda
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03-15-2006, 02:43 PM
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Guest
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Posts: 77
Hysterectomy: November 9th, 2005
Surgery Type: SAH
Ovaries: Removed both
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Anyone had to fight with the insurance company?
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Quote: |
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Originally Posted by Voo
If the appeals do not go your way, then the last step is to appeal with your State Dept. of Insurance.
The only bright side of this process is that at least while everything is being appealed, the bills are on hold, and that buys time to save some money.
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Case & Point, I just lost a friend
last November (it started with breast
cancer then spread) She was wife and
mother of 3 small children, who was in
fact a "registered nurse" in the ICU unit.
Also mis-diagnosed, until it was too late.
Do insurance companies realize they are
playing roulette with our health & lives?
Political Medical Protocol, c'mon people!
what if this were "your wife" or daughter?
I was sent to an "American GYN specialist"
top in his field. He mis-diagnosed me,
he found 1 tumor & 1 cyst, that's all...
(while India doctors dicovered all below)
only 1 month to the day after seeing the
American GYN "Specialist"
he put me on "medication" (provera) and
sent me home to 'wait it out" for another
6 months ~ before he would even consider
doing a hysterectomy...all the while I am
enduring needless suffering, least we mention
blinding pain that felt like full blown labor
with bleeding (gushers) to the shoes! I felt
violated, ignored and not cared for. In fact
I was told "most peri-menopausal women"
experience the same ~ pretty much sum's
it up to say he told me to "tough it out"...
I didn't listen to the Amercain GYN
"specialist's" advice, and thank Heaven's
I took control of my own body before it
was 'too late" ~ Praise God!!!
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03-15-2006, 03:01 PM
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Guest
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Posts: 541
Hysterectomy: April 3rd, 2006
Surgery Type: TAH/SAH
Ovaries: Kept 1 or both
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Anyone had to fight with the insurance company?
The american insurance companies are in it strictly for the money. they charge us for premiums then make us jump through hoops like show pony's to get approved for services. 60 minutes had a show about hospitals who charge people without insurance more money than those with. Hospitals say NO...we charge the same rete, but people with insurance get a negotiated rate from the insurance company...doesn't that sound backward?
I had to fight for this surgery and I won the fight, but it was weeks of dealing with idiots. Our government does nothing about the rising cost of health care and the fact that companies are struggling to insure their employees....I can't imagine what it will be like when I retire, that thought is scary.
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03-15-2006, 11:10 PM
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Posts: 30,771
Hysterectomy: February 4th, 2002
Surgery Type: TVH
Ovaries: Removed both
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Anyone had to fight with the insurance company?
(((Ladies))) I feel for anyone who has to add worries about whether or not something will be covered by their insurance to all the other things we worry about when anticipating (or recovering from) surgery. It's a very vulnerable time for us, and not the best time to have to have money woes.
Just a word about the insurance industry... first, yes, insurance companies, like all businesses, need to make money. If they don't, they go out of business -- and that would be even worse than having to work with them. They employ many, many mathematicians who help them calculate what the odds are they'll have to pay how much for what procedures and services in the course of any particular individual's life, based on lots of statistical risk factors. Their goal, and they don't try to hide this, is to make sure we pay them more (in aggregate) than they pay us over the course of our lifetimes, and that's how they figure out what premiums to charge.
As for the negotiated bills they pay to medical providers that are in their network... the reason that is acceptable is that they providers are making a tradeoff. When they deal with an insurance company, they know the insurance company can and will pay, assuming there is coverage. They are willing to accept less money for a sure thing versus dealing with an individual patient, who may or may not be willing/able to pay or may take a very long time to do so, or (and this happens more often than we'd think) declare bankruptcy and avoid payment that way. The hospitals' billing practice is based on the principles of the time value of money and with their estimate of the probability of getting paid by an individual versus a big insurance company. While it seems unfair, or cold, it's how hospitals and insurance companies can afford to stay in business.
If insurance companies had to pay all (even in-network) hospitals the full billed amount for everything, they would have to pass that on to us in the form of much higher premiums. If hospitals lowered their bills to private parties to the negotiated amounts they have with big insurance companies they are providers for, they'd have to cut costs (for example, hire fewer nurses and technicians, pay their employees less, you get the idea) or face being shut down. It's a very precarious balance the way the system works right now, and to tip it in any direction is to invite disaster
(((Voo))) Has your insurance company said it will not cover the breast biopsy at this point? How big are the microcalcifications? If it's a pretty small area, I doubt very much that the insurance company is going to call that pre-existing - but if it's larger, they may claim that you should have been having regular mammograms and have probably had this problem for quite a long time. To give you an idea of how they can do that... I was diagnosed with breast cancer two years ago after a routine mammogram (I'd been having them faithfully every year up to then, all clear) showed suspicious microcalcifications. The area was about 1 cm in diameter. I was told that it can take 7-10 years for DCIS to get started and get to that size, which means I'd actually had it for a long time, but it only got to where the mammography could detect it that year. If I had not been having regular (clear) mammograms, and/or the area had been a lot larger, I can definitely see where they could claim it was pre-existing.
Hopefully, your DR can get the biopsy pre-authorized with no problem. If not, and you have to wait, try to remember that these microcalcifications are almost always due to benign causes, and the ones that aren't, are due to cancers that grow very very slowly, such as mine. That's why often the first time microcalcifications show up in a mammogram, the recommendation is just to wait six months and recheck it to see if there are any changes that would warrant a biopsy.
Again, I'm sorry to hear you are struggling with getting coverage from your insurer. I just wanted to say that they're not purposely trying to make our lives difficult, they're just trying to stay in business. For every bad decision made by an insurance company (and hopefully appealed!), there's a bogus claim being made by a greedy individual who thinks he or she can cheat the insurance company and win. Neither is OK, but the abuses by individuals is a big part of why they are so cautious about approving coverage. No system is perfect, but this is the one we have.
s,
-Linda
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03-16-2006, 02:43 AM
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HysterSister
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Posts: 412
Hysterectomy: April 26th, 1982
Ovaries: Undecided
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Anyone had to fight with the insurance company?
Voo,
Just wanted to say that even if you apeal and they say no, there is always the State Insurance Board. I have filed complaints twice against 2 different insurance companies, and they really were on my side. There may be exceptions in the policy that you are not aware of. it almost takes a lawyer to read these things. File your complaint with your state board, and tell them in your own words of your medical necissity and the problems your are experiencing. Do not downplay your symptoms or be stoic. Appeal to them as a human. I have found that if they can help you , if they can find that loophole, they will. don't give up , they (the insurance co) count on that. They know most people will not take them to task , and so a lot of people just give up. I only give up when all routes have been exhausted.
I'm not saying it can always circumvented, but there may be a legal way, a loophole in the policy and if the state board gets on them, they will find it quickly.
good luck. America can be a hard place to live in , 900 month is a lot to pay, and still have to fight like this for coverage.
to add not advising yu to cheat insurance co or file bogus claim just to make sure you have exhausted all legal avenues. I find the state insurance board knows your rights pretty well.
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