What to do when your insurance company says "No."
Mary D.* would rather forget the whole ordeal. In
1992, she was suffering from weakness in both her left arm and leg.
To get to the root of the problem, her doctor ordered an electromyography
(nerve test) on both limbs.
Mary's HMO, United HealthCare, balked at testing both
limbs at once, and said that it would only cover one test at a time.
"The problem was for the doctor to get an accurate
diagnosis, I needed both tests done at the same time," she
Mary absorbed the $2,500 cost of one of the myographies,
because she couldn't get the insurance company to budge on their
But, that's not the end of her story. Mary's doctor
also ordered an MRI (magnetic reasoning image) that UHC told her
they refused to cover, stating the test could only be performed
once a year. After battling for over a year with UHC, she got the
Mary's battle with her HMO would turn into a three-year
war. Since she also suffered from bad circulation, due to congenital
heart disease, her doctor ordered an electric bed. His thinking
was that if she slept upright, her circulation would improve. The
insurance company again denied coverage for the $2,300 bed, claiming
it wasn't "medically necessary."
The nightmare continued. Mary says that the insurance
company also turned down coverage for medication prescribed by her
doctor. After fighting for three years, Mary was emotionally spent,
and gave up. She wound up footing her own bill for both the bed
and medicine as well.
"It was a slew of paperwork," she recalls. "The worst
part was the length of time getting to the customer-service line
during the day -- during work hours. And they would never
call back. Every time they said that 'we have no paperwork.' I sent
the paperwork certified mail with returned receipt three times.
Finally, after a year, they said they had the paperwork, but 'there
was nothing we can do about it.'"
"It's not the way we like to do business," candidly
says Phil Soucheray, spokesman for UHC in Minneapolis. "Certainly,
our goal is to get people the right coverage at the right time;
at the right place. It may be difficult now to access exactly what
happened in 1992. It certainly doesn't reflect how times have changed.
"The sad fact is that stories like this are deserved.
We can't hide from the fact that at times United HealthCare or other
insurance companies got in the way. It's not the way it's supposed
to work. While we don't like it, we've got to make sure things like
this don't happen again."
Soucheray offered Mary the option for UHC to take
another look at her case, which she declined, citing an unwillingness
to deal with the insurance company any further.
There are two kinds of rejections
Is Mary's case an aberration from the past or is this
treatment a persistent problem with insurance companies and HMOs?
"There's a balance going on," says David Sterling,
president of Sterling and Sterling Inc., an insurance brokerage
in Great Neck, N.Y. "In some cases, an insurance company is inappropriately
turning down what should be covered. In other cases, they're appropriately
turning down something that's not covered by the plan, but it's
Sterling cites examples of legitimate rejections by
insurance companies, such as heart transplants, that are clearly
listed as not covered by some policies.
"The insurance company rejects the coverage legitimately
to save costs," he explains. "But someone's going to die if they
don't have the transplant. In the newspaper, it still doesn't sound
or feel very good."
Who's to blame?
However, Sterling says that there are many times when
an insurance company can't be blamed for denying coverage.
"Ninety-nine percent of the time, coverage is denied
when a doctor completes an insurance form and enters the wrong code,"
he estimates. "The insurance company sees the wrong code, and [if
you want coverage], you'll have to resubmit."
For example, an insurance company doesn't cover a
nose job (rhinoplasty), because the procedure is considered cosmetic.
But if a tumor is removed from someone's nose, and plastic surgery
is needed to reconstruct the nose, that's a legitimate claim. Still,
if the doctor lists the procedure as merely a rhinoplasty, the insurance
company will be apt to deny, unless it's clear to them why the nose
Jim Walsh, editor of "Hassle Free Healthcare" for
Silver Lake Publishing in Los Angeles, claims that many times the
finger can be pointed at employers, instead of directly at the insurance
company. Many companies dictate what coverage they want their employees
to have, based on cost containment.
"It's not always the big, bad insurance company denying
claims," he says. "The carrier is under pressure from the employer
to keep costs down, especially in big companies."
In that case, some things like experimental treatments,
procedures and prescription drugs get excluded from the plan.
What can you do?
Dr. Vincent Riccardi is president and founder of American
Medical Consumers, a La Crescenta, Calif.-based company that helps
insured patients appeal denied claims. Riccardi once served on an
insurance company's coverage decision board -- a 10-month period
that he described as "terrible." Riccardi offers the following tips
when appealing denied charges:
Get copies of your medical
records and contact the doctors used in the medical process,
to see if the forms were filled out properly, and if they need
to be resubmitted. Often, a claim is denied due to a misunderstanding
or incomplete evidence. "Anyone denied coverage should question
the denial," he says. "In all likelihood, it was due to a poor
If the insurance company refuses
your resubmitted claim, go a step further. Riccardi's company
consults with consumers on how to contact and best submit an
appeal to the proper Independent Practice Association. This
is a review board of physicians that determines if the correct
decision on a case was made.
Finally, Walsh adds to Riccardi's
suggestions by saying that if the situation is not resolved
satisfactorily, contact your state's insurance commissioner.
However, Walsh admits that the appeals process is a better bet.
"It's an old story," states Walsh. "The insurance
company has all the time in the world, and you don't."
In Mary's mind, the hourglass ran out a long time
-- Posted: July 6, 1999