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Coverage denied!
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 laments.

Mary absorbed the $2,500 cost of one of the myographies, because she couldn't get the insurance company to budge on their denial.

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 MRI covered.

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.'"

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"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 hurting people."

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 needed reconstruction.

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 document submitted."

  • 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 ago.

*Name changed to protect confidentiality of the patient

-- Posted: July 6, 1999


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